Healthcare Provider Details

I. General information

NPI: 1902381189
Provider Name (Legal Business Name): WILLIAM NEEDHAM NNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2018
Last Update Date: 10/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST
JACKSON MS
39216-4500
US

IV. Provider business mailing address

2500 N STATE ST
JACKSON MS
39216-4500
US

V. Phone/Fax

Practice location:
  • Phone: 601-815-7100
  • Fax:
Mailing address:
  • Phone: 601-815-7100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number902873
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: