Healthcare Provider Details

I. General information

NPI: 1780610444
Provider Name (Legal Business Name): SALOUM CISSE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2006
Last Update Date: 11/21/2023
Certification Date: 11/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 S OAK SUITE 2
RAYMOND MS
39154-4205
US

IV. Provider business mailing address

PO BOX 321359
FLOWOOD MS
39232-1359
US

V. Phone/Fax

Practice location:
  • Phone: 601-526-0790
  • Fax: 601-526-0795
Mailing address:
  • Phone: 601-936-1395
  • Fax: 601-526-0795

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number18216
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number18216
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: