Healthcare Provider Details

I. General information

NPI: 1760437875
Provider Name (Legal Business Name): LANCE DEWEY WHALEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: CAROLYN E. GASKILL RN

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 03/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 S MAIN ST
SARDIS MS
38666-1721
US

IV. Provider business mailing address

116 S MAIN ST
SARDIS MS
38666-1721
US

V. Phone/Fax

Practice location:
  • Phone: 662-487-1605
  • Fax: 662-487-9068
Mailing address:
  • Phone: 662-487-1605
  • Fax: 662-487-9068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number06684
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: