Healthcare Provider Details

I. General information

NPI: 1871006155
Provider Name (Legal Business Name): DMC II INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2017
Last Update Date: 11/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4508 HIGHWAY 45 N
COLUMBUS MS
39705-2917
US

IV. Provider business mailing address

450 E PRESIDENT AVE
TUPELO MS
38801-5599
US

V. Phone/Fax

Practice location:
  • Phone: 662-328-9702
  • Fax: 662-328-0954
Mailing address:
  • Phone: 662-377-4685
  • Fax: 662-377-2057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number06164
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number876972
License Number StateMS
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number13912
License Number StateMS

VIII. Authorized Official

Name: JOSEPH GILLIS
Title or Position: OWNER
Credential:
Phone: 662-327-5202