Healthcare Provider Details

I. General information

NPI: 1497976617
Provider Name (Legal Business Name): LISA MYERS SULLIVAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 11/11/2015
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 NORTH STATE STREET
JACKSON MS
39216-4500
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-1530
  • Fax:
Mailing address:
  • Phone: 601-815-9824
  • Fax: 601-815-0434

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number0116017500
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number23387
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: