Healthcare Provider Details

I. General information

NPI: 1548655053
Provider Name (Legal Business Name): MISSISSIPPI UROLOGY OUTPATIENT SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2015
Last Update Date: 03/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 MARSHALL ST SUITE 201
JACKSON MS
39202-1651
US

IV. Provider business mailing address

501 MARSHALL ST SUITE 201
JACKSON MS
39202-1651
US

V. Phone/Fax

Practice location:
  • Phone: 601-353-9900
  • Fax: 601-353-3654
Mailing address:
  • Phone: 601-353-9900
  • Fax: 601-353-3654

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. HAROLD J BLALOCK
Title or Position: OWNER
Credential: MD
Phone: 601-353-9900