Healthcare Provider Details

I. General information

NPI: 1609973056
Provider Name (Legal Business Name): ALLIANCE HEALTHCARE SYSTEM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

538 J. M. ASH RD.
HOLLY SPRINGS MS
38635-3238
US

IV. Provider business mailing address

538 ASH RD.
HOLLY SPRINGS MS
38635-5040
US

V. Phone/Fax

Practice location:
  • Phone: 662-252-1599
  • Fax:
Mailing address:
  • Phone: 662-252-1599
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. RICHARD GOODMAN WISEMAN
Title or Position: EMPLOYEE
Credential: FNP
Phone: 662-252-1599