Healthcare Provider Details

I. General information

NPI: 1245755990
Provider Name (Legal Business Name): PATHWAY HEALTHCARE- COLUMBUS, MS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 BLUECUTT RD STE 200
COLUMBUS MS
39705-1303
US

IV. Provider business mailing address

37 SANDSTONE CIR STE 92
JACKSON TN
38305-3168
US

V. Phone/Fax

Practice location:
  • Phone: 731-265-6025
  • Fax: 731-265-6028
Mailing address:
  • Phone: 731-265-6025
  • Fax: 731-265-6028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: KRYSTAL SPENCER
Title or Position: BUSINESS OFFICE MANAGER
Credential:
Phone: 731-265-6025