Healthcare Provider Details

I. General information

NPI: 1356103527
Provider Name (Legal Business Name): RH EMERGENCY MEDICINE OF JEFFERSON DAVIS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2024
Last Update Date: 09/26/2024
Certification Date: 09/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1102 ROSE ST
PRENTISS MS
39474-5200
US

IV. Provider business mailing address

PO BOX 7058
TUPELO MS
38802-7058
US

V. Phone/Fax

Practice location:
  • Phone: 601-792-4276
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER KATHRYN WAKEFORD
Title or Position: ENTERPRISE CFO
Credential:
Phone: 205-901-5103