Healthcare Provider Details

I. General information

NPI: 1043462195
Provider Name (Legal Business Name): INTERNAL MEDICINE ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2008
Last Update Date: 10/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

551 AZALEA DR
OXFORD MS
38655-7900
US

IV. Provider business mailing address

740 NOTTINGHAM DR
OXFORD MS
38655-4414
US

V. Phone/Fax

Practice location:
  • Phone: 662-234-0332
  • Fax:
Mailing address:
  • Phone: 662-816-6349
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberD1035
License Number StateMS

VIII. Authorized Official

Name: JEANNETTE SMITH CLEMENTS
Title or Position: REGISTERED DIETITIAN
Credential: R.D.
Phone: 662-816-6349