Healthcare Provider Details

I. General information

NPI: 1396059093
Provider Name (Legal Business Name): MISS REPRODUCTIVE MEDICINE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2010
Last Update Date: 08/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 RIVER OAKS DR
JACKSON MS
39232-9530
US

IV. Provider business mailing address

1040 RIVER OAKS DR
JACKSON MS
39232-9530
US

V. Phone/Fax

Practice location:
  • Phone: 601-936-3650
  • Fax: 866-491-0274
Mailing address:
  • Phone: 601-936-3650
  • Fax: 866-491-0274

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License Number12123
License Number StateMS

VIII. Authorized Official

Name: DR. RANDALL S HINES
Title or Position: OWNER
Credential: MD
Phone: 601-936-3650