Healthcare Provider Details

I. General information

NPI: 1376109207
Provider Name (Legal Business Name): SOUTHWEST MISSISSIPPI ENT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2019
Last Update Date: 05/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 MARION AVE
MCCOMB MS
39648-2709
US

IV. Provider business mailing address

405 MARION AVE
MCCOMB MS
39648-2709
US

V. Phone/Fax

Practice location:
  • Phone: 601-684-1250
  • Fax: 601-684-0129
Mailing address:
  • Phone: 601-684-1250
  • Fax: 601-684-0129

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM K. AUSTIN
Title or Position: MEMBER
Credential: MD
Phone: 601-684-1250