Healthcare Provider Details

I. General information

NPI: 1508386582
Provider Name (Legal Business Name): ELEMENTS MEDICAL GROUP OF MISSISSIPPI INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2017
Last Update Date: 06/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3949 HIGHWAY 43 N
BRANDON MS
39047-7240
US

IV. Provider business mailing address

PO BOX 671673
DALLAS TX
75267-1673
US

V. Phone/Fax

Practice location:
  • Phone: 601-829-2500
  • Fax: 601-829-4278
Mailing address:
  • Phone: 562-303-9718
  • Fax: 562-264-1219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number862194
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number850823
License Number StateMS
# 4
Primary TaxonomyY
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number7875
License Number StateMS

VIII. Authorized Official

Name: CHERYL MAPLESDEN
Title or Position: SR DIRECTOR RCM
Credential:
Phone: 615-540-3708