Healthcare Provider Details

I. General information

NPI: 1235329020
Provider Name (Legal Business Name): CENTER OF INFECTIOUS DISEASE EXCELLENCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

1040 RIVER OAKS DR SUITE 303
JACKSON MS
39232-9530
US

IV. Provider business mailing address

1040 RIVER OAKS DR SUITE 303
JACKSON MS
39232-9530
US

V. Phone/Fax

Practice location:
  • Phone: 601-936-0706
  • Fax: 601-936-6150
Mailing address:
  • Phone: 601-936-0706
  • Fax: 601-936-6150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: BRAD SINCLAIR
Title or Position: REGIONAL MANAGER
Credential:
Phone: 601-936-3102