Healthcare Provider Details

I. General information

NPI: 1740636786
Provider Name (Legal Business Name): MISSISSIPPI CENTER FOR ADVANCED MEDICINE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2016
Last Update Date: 10/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7731 OLD CANTON RD STE B
MADISON MS
39110-6115
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 TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number14837/1.1
License Number StateMS

VIII. Authorized Official

Name: SPENCER SULLIVAN
Title or Position: PRESIDENT AND CEO
Credential: MD
Phone: 601-863-9764