Healthcare Provider Details

I. General information

NPI: 1063491843
Provider Name (Legal Business Name): MED-SOUTH, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2006
Last Update Date: 05/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7048 OLD CANTON RD STE 220
RIDGELAND MS
39157-1021
US

IV. Provider business mailing address

PO BOX 1277
JACKSON MS
39215-1277
US

V. Phone/Fax

Practice location:
  • Phone: 601-933-8400
  • Fax: 601-933-1103
Mailing address:
  • Phone: 601-933-8400
  • Fax: 601-933-1103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number04720/11.1
License Number StateMS

VIII. Authorized Official

Name: TROY TODD KESTENBAUM
Title or Position: VICE PRESIDENT
Credential:
Phone: 601-933-8400