Healthcare Provider Details

I. General information

NPI: 1124253521
Provider Name (Legal Business Name): JEREMY K SMALLWOOD RPA/RA, RT(R)(VI)
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2009
Last Update Date: 05/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3109 BIENVILLE BLVD
OCEAN SPRINGS MS
39564-4361
US

IV. Provider business mailing address

3109 BIENVILLE BLVD
OCEAN SPRINGS MS
39564-4361
US

V. Phone/Fax

Practice location:
  • Phone: 228-818-1117
  • Fax: 228-818-6090
Mailing address:
  • Phone: 228-818-1117
  • Fax: 228-818-6090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code243U00000X
TaxonomyRadiology Practitioner Assistant
License Number
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code2471V0106X
TaxonomyVascular-Interventional Technology Radiologic Technologist
License Number
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: