Basic Information
| Provider Information | |||||||||
| NPI: | 1831123751 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DMED | ||||||||
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| OtherOrganizationName: | DMED | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 55671 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392965671 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6015730386 | ||||||||
| FaxNumber: | 6018568003 | ||||||||
| Practice Location | |||||||||
| Address1: | 558 HIGHWAY 6 E | ||||||||
| Address2: | SUITE B | ||||||||
| City: | BATESVILLE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 386063002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6629341076 | ||||||||
| FaxNumber: | 6625630155 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CORKERN | ||||||||
| AuthorizedOfficialFirstName: | EDITH | ||||||||
| AuthorizedOfficialMiddleName: | MELISSA | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6015730386 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | RN | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | MS | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 03720722 | 05 | MS | MEDICAID |