Healthcare Provider Details

I. General information

NPI: 1194894147
Provider Name (Legal Business Name): MIDSOUTH MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 04/12/2023
Certification Date: 04/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2149 STATELINE RD W
SOUTHAVEN MS
38671-1222
US

IV. Provider business mailing address

2149 STATELINE RD W
SOUTHAVEN MS
38671-1222
US

V. Phone/Fax

Practice location:
  • Phone: 662-342-1112
  • Fax: 662-342-1116
Mailing address:
  • Phone: 662-342-1112
  • Fax: 662-342-1116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number18647
License Number StateMS

VIII. Authorized Official

Name: DR. CIAO ZHENG NEWMAN
Title or Position: PRESIDENT
Credential: M.D., B.S., M.A.
Phone: 662-342-1112