Healthcare Provider Details

I. General information

NPI: 1750510962
Provider Name (Legal Business Name): JASON ROBERT SCHWANEBECK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2009
Last Update Date: 07/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIVERSITY OF MISSISIPPI MEDICAL CENTER 2500 NORTH STATE STREET
JACKSON MS
39216-4505
US

IV. Provider business mailing address

110 POST OAK DR
BRANDON MS
39047-7298
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-5570
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberT-2242
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: