Healthcare Provider Details

I. General information

NPI: 1144631649
Provider Name (Legal Business Name): ANDREW RICHARD HAYSLETT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2014
Last Update Date: 11/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N. STATE ST. UMMC, DEPARTMENT OF PEDIATRICS
JACKSON MS
39216
US

IV. Provider business mailing address

2500 N. STATE ST. CBO - SUITE 4200
JACKSON MS
39216-4500
US

V. Phone/Fax

Practice location:
  • Phone: 601-815-6211
  • Fax: 601-815-8250
Mailing address:
  • Phone: 601-496-9794
  • Fax: 601-815-0434

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25144
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: