Healthcare Provider Details

I. General information

NPI: 1174979199
Provider Name (Legal Business Name): PRX LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2016
Last Update Date: 05/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 RAWLS SPRINGS LOOP RD
HATTIESBURG MS
39402-7801
US

IV. Provider business mailing address

20 RAWLS SPRINGS LOOP RD
HATTIESBURG MS
39402-7801
US

V. Phone/Fax

Practice location:
  • Phone: 601-582-6069
  • Fax: 601-579-4842
Mailing address:
  • Phone: 601-582-6069
  • Fax: 601-579-4842

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P2900X
TaxonomyPain Medicine (Psychiatry & Neurology) Physician
License Number21276
License Number StateMS

VIII. Authorized Official

Name: MR. KENNETH CONWAY
Title or Position: CFO
Credential:
Phone: 601-543-2849