Healthcare Provider Details

I. General information

NPI: 1366014128
Provider Name (Legal Business Name): SOUTH MISSISSIPPI WOUND MANAGEMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2021
Last Update Date: 07/14/2021
Certification Date: 07/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

427 HIGHWAY 51 N
BROOKHAVEN MS
39601-2350
US

IV. Provider business mailing address

1600 N STATE ST STE 400
JACKSON MS
39202-1689
US

V. Phone/Fax

Practice location:
  • Phone: 601-835-9444
  • Fax: 601-833-5210
Mailing address:
  • Phone: 601-944-1717
  • Fax: 601-944-9780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: BRADLEY J MARTIN
Title or Position: MANAGER
Credential: PA
Phone: 601-757-6192