Healthcare Provider Details

I. General information

NPI: 1982608691
Provider Name (Legal Business Name): SOUTHERN FAMILY MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 01/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

603 S HOLLY AVE
COLLINS MS
39428-3801
US

IV. Provider business mailing address

606 GERALD MCRANEY ST
COLLINS MS
39428-3801
US

V. Phone/Fax

Practice location:
  • Phone: 601-765-9393
  • Fax: 601-765-9363
Mailing address:
  • Phone: 601-765-9393
  • Fax: 601-765-9363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JASON GREGORY BEASLEY
Title or Position: OWNER
Credential: MD
Phone: 601-765-9393