Healthcare Provider Details

I. General information

NPI: 1568764504
Provider Name (Legal Business Name): DIABETES AND ENDOCRINE CENTER OF MS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/24/2010
Last Update Date: 05/30/2023
Certification Date: 05/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

971 LAKELAND DR SUITE 450
JACKSON MS
39216-4643
US

IV. Provider business mailing address

971 LAKELAND DR SUITE 450
JACKSON MS
39216-4643
US

V. Phone/Fax

Practice location:
  • Phone: 601-948-5158
  • Fax: 601-326-4265
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number19640
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number21031
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number20965
License Number StateMS
# 4
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State

VIII. Authorized Official

Name: TERRI FEWELL
Title or Position: OFFICE MANAGER
Credential:
Phone: 601-292-1228