Healthcare Provider Details

I. General information

NPI: 1124265665
Provider Name (Legal Business Name): ALEXANDER VORTMEYER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: ALEXANDER O. VORTMEYER MD

II. Dates (important events)

Enumeration Date: 01/20/2009
Last Update Date: 01/05/2024
Certification Date: 01/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST
JACKSON MS
39216-4500
US

IV. Provider business mailing address

504 CLINTON CENTER DR STE 4300
CLINTON MS
39056-5610
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-1530
  • Fax: 601-984-1531
Mailing address:
  • Phone: 601-815-2005
  • Fax: 601-815-0434

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZN0500X
TaxonomyNeuropathology Physician
License Number31757
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code207ZN0500X
TaxonomyNeuropathology Physician
License Number047068
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: