Healthcare Provider Details

I. General information

NPI: 1790227627
Provider Name (Legal Business Name): MISSISSIPPI CENTER FOR ADVANCED MEDICINE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2016
Last Update Date: 12/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7731 OLD CANTON RD SUITE B
MADISON MS
39110-6114
US

IV. Provider business mailing address

7731 OLD CANTON RD SUITE B
MADISON MS
39110-6114
US

V. Phone/Fax

Practice location:
  • Phone: 601-499-0935
  • Fax: 601-499-0936
Mailing address:
  • Phone: 601-499-0935
  • Fax: 601-499-0936

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number23304
License Number StateMS

VIII. Authorized Official

Name: DR. SPENCER K SULLIVAN
Title or Position: PRESIDENT/CEO
Credential: M.D.
Phone: 601-499-0935