Healthcare Provider Details

I. General information

NPI: 1396894234
Provider Name (Legal Business Name): SOUTHWEST MS NEPHROLOGY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 10/18/2023
Certification Date: 10/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

513C BROOKMAN DR
BROOKHAVEN MS
39601-2326
US

IV. Provider business mailing address

513C BROOKMAN DR
BROOKHAVEN MS
39601-2326
US

V. Phone/Fax

Practice location:
  • Phone: 601-833-3822
  • Fax: 601-835-4330
Mailing address:
  • Phone: 601-833-3822
  • Fax: 601-835-4330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number StateMS

VIII. Authorized Official

Name: RICHARD ERIC MILLER
Title or Position: PARTNER
Credential: MD
Phone: 601-405-1593