Healthcare Provider Details

I. General information

NPI: 1538178777
Provider Name (Legal Business Name): ANDREW GEORGE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 12/06/2022
Certification Date: 10/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

283 W RACE ST
ROLLING FORK MS
39159-2621
US

IV. Provider business mailing address

283 W RACE ST
ROLLING FORK MS
39159-2621
US

V. Phone/Fax

Practice location:
  • Phone: 662-873-0477
  • Fax: 662-655-1236
Mailing address:
  • Phone: 662-873-0477
  • Fax: 662-655-1236

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:
Title or Position:
Credential:
Phone: