Healthcare Provider Details

I. General information

NPI: 1548720527
Provider Name (Legal Business Name): MISSISSIPPI CENTER FOR ADVANCED MEDICINE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2019
Last Update Date: 09/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2053 GAUSE BLVD E STE 200
SLIDELL LA
70461-5451
US

IV. Provider business mailing address

7731 OLD CANTON RD STE B
MADISON MS
39110-6115
US

V. Phone/Fax

Practice location:
  • Phone: 985-259-8045
  • Fax: 601-499-0311
Mailing address:
  • Phone: 601-499-0935
  • Fax: 601-499-0311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: SPENCER K SULLIVAN
Title or Position: CEO/OWNER
Credential: MD
Phone: 601-499-0935