Healthcare Provider Details

I. General information

NPI: 1669571329
Provider Name (Legal Business Name): SUZANNE SANDERS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 04/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 E WOODROW WILSON AVE
JACKSON MS
39216-5116
US

IV. Provider business mailing address

1500 E WOODROW WILSON AVE MEDICAL SERVICE (111)
JACKSON MS
39216-5116
US

V. Phone/Fax

Practice location:
  • Phone: 601-362-4471
  • Fax: 601-364-1327
Mailing address:
  • Phone: 601-362-4471
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number15965
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: