Healthcare Provider Details

I. General information

NPI: 1902685191
Provider Name (Legal Business Name): STEVELAND EDWARDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2023
Last Update Date: 09/26/2023
Certification Date: 09/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

381 REED AVE
JACKSON MS
39206-3656
US

IV. Provider business mailing address

381 REED AVE
JACKSON MS
39206-3656
US

V. Phone/Fax

Practice location:
  • Phone: 601-961-9460
  • Fax:
Mailing address:
  • Phone: 601-961-9460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number207QA0505X
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: