Healthcare Provider Details

I. General information

NPI: 1992034771
Provider Name (Legal Business Name): SOUTHEAST UROGYNECOLOGY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2009
Last Update Date: 02/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 MARSHALL ST SUITE 607-A
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:
Mailing address:
  • Phone: 601-948-6540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. ROBERT L HARRIS
Title or Position: DIRECTOR
Credential: M.D.
Phone: 601-948-6540