Healthcare Provider Details

I. General information

NPI: 1417291451
Provider Name (Legal Business Name): UROGYN DIAGNOSTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2012
Last Update Date: 03/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 MARSHALL ST SUITE 600
JACKSON MS
39202-1651
US

IV. Provider business mailing address

501 MARSHALL ST SUITE 600
JACKSON MS
39202-1651
US

V. Phone/Fax

Practice location:
  • Phone: 601-948-6540
  • Fax: 601-326-1501
Mailing address:
  • Phone: 601-948-6540
  • Fax: 601-326-1501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. JULIE FERGUSON
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 601-948-6540