Healthcare Provider Details

I. General information

NPI: 1730109240
Provider Name (Legal Business Name): BELLE MEADE MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 BELLE MEADE POINTE
FLOWOOD MS
39232
US

IV. Provider business mailing address

108 BELLE MEADE POINTE
FLOWOOD MS
39232
US

V. Phone/Fax

Practice location:
  • Phone: 601-992-7002
  • Fax:
Mailing address:
  • Phone: 601-992-7002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number14462
License Number StateMS

VIII. Authorized Official

Name: MIRIAM SHATLEY
Title or Position: MANAGER
Credential: M.D.
Phone: 601-992-7002