Healthcare Provider Details

I. General information

NPI: 1023070893
Provider Name (Legal Business Name): LELAND LOU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 11/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1314 19TH AVE
MERIDIAN MS
39301-4116
US

IV. Provider business mailing address

PO BOX 5183
MERIDIAN MS
39302-5183
US

V. Phone/Fax

Practice location:
  • Phone: 601-703-4362
  • Fax: 601-703-9321
Mailing address:
  • Phone: 601-703-4282
  • Fax: 601-703-4597

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number20093
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: