Healthcare Provider Details

I. General information

NPI: 1558460642
Provider Name (Legal Business Name): INTERNAL MEDICINE & PEDIATRIC ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 01/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6919 OLD CANTON RD
RIDGELAND MS
39157-1268
US

IV. Provider business mailing address

6919 OLD CANTON RD
RIDGELAND MS
39157-1268
US

V. Phone/Fax

Practice location:
  • Phone: 601-956-0911
  • Fax:
Mailing address:
  • Phone: 601-956-0911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number16465
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number16465
License Number StateMS

VIII. Authorized Official

Name: MANISHA SETHI
Title or Position: MANAGER
Credential: M.D.
Phone: 601-956-0911