Healthcare Provider Details

I. General information

NPI: 1952395899
Provider Name (Legal Business Name): GREG P TAVAI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5001 HARDY ST
HATTIESBURG MS
39402-1308
US

IV. Provider business mailing address

PO BOX 22505
JACKSON MS
39225-2505
US

V. Phone/Fax

Practice location:
  • Phone: 601-268-8000
  • Fax:
Mailing address:
  • Phone: 866-321-8433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number18639
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: