Healthcare Provider Details

I. General information

NPI: 1548996069
Provider Name (Legal Business Name): RMC DIABETES CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2022
Last Update Date: 12/20/2022
Certification Date: 12/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

794 HIGHWAY 51 STE A
MADISON MS
39110-9662
US

IV. Provider business mailing address

794 HIGHWAY 51 STE A
MADISON MS
39110-9662
US

V. Phone/Fax

Practice location:
  • Phone: 601-790-7711
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: BARBARA BRADLEY
Title or Position: AUTHORIZED OFFICIAL / OWNER
Credential:
Phone: 601-575-3392