Healthcare Provider Details

I. General information

NPI: 1477741494
Provider Name (Legal Business Name): ANDREW GEORGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2007
Last Update Date: 10/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 S FOURTH ST
ROLLING FORK MS
39159-5146
US

IV. Provider business mailing address

25 S FOURTH ST
ROLLING FORK MS
39159-5146
US

V. Phone/Fax

Practice location:
  • Phone: 662-873-0477
  • Fax: 662-873-0742
Mailing address:
  • Phone: 662-873-0477
  • Fax: 662-873-0742

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number13643
License Number StateMS

VIII. Authorized Official

Name: ANDREW GEORGE
Title or Position: OWNER
Credential: MD
Phone: 662-873-0477