Healthcare Provider Details

I. General information

NPI: 1144257460
Provider Name (Legal Business Name): ALBERT W DREISBACH III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 03/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 NORTH STATE STREET DEPARTMENT OF MEDICINE DIVISION OF NEPHROLOGY
JACKSON MS
39216
US

IV. Provider business mailing address

2500 N STATE ST DEPT OF MEDICINE DIVISION OF NEPHROLOGY
JACKSON MS
39216-4500
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-5687
  • Fax:
Mailing address:
  • Phone: 601-984-5687
  • Fax: 601-984-5765

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number19442
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: