Healthcare Provider Details

I. General information

NPI: 1750499067
Provider Name (Legal Business Name): MELISSA A BREITLING MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3102 GOODMAN RD W
HORN LAKE MS
38637-1172
US

IV. Provider business mailing address

PO BOX 39
SOUTHAVEN MS
38671-0001
US

V. Phone/Fax

Practice location:
  • Phone: 662-342-6677
  • Fax: 662-393-8819
Mailing address:
  • Phone: 901-488-8583
  • Fax: 662-393-8819

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number17459
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: