Healthcare Provider Details

I. General information

NPI: 1952344483
Provider Name (Legal Business Name): MARSHALL PAUL VANCE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 10/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 FOOTE ST
CORINTH MS
38834-4834
US

IV. Provider business mailing address

PO BOX 839
CORINTH MS
38835-0839
US

V. Phone/Fax

Practice location:
  • Phone: 662-287-4424
  • Fax:
Mailing address:
  • Phone: 662-286-9883
  • Fax: 662-284-9836

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number39303
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number0101265228
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number26167
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: