Healthcare Provider Details

I. General information

NPI: 1376506741
Provider Name (Legal Business Name): TIMOTHY M. SOUTH FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2006
Last Update Date: 10/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

332 HIGHWAY 12 W
KOSCIUSKO MS
39090-3209
US

IV. Provider business mailing address

332 HIGHWAY 12 W
KOSCIUSKO MS
39090-3209
US

V. Phone/Fax

Practice location:
  • Phone: 662-289-1800
  • Fax: 662-289-2486
Mailing address:
  • Phone: 662-289-1800
  • Fax: 662-289-2486

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR701483
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: