Healthcare Provider Details

I. General information

NPI: 1982783619
Provider Name (Legal Business Name): PROGRESSIVE PHYSICIANS PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 11/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8412 AIRWAYS BLVD
SOUTHAVEN MS
38671-5140
US

IV. Provider business mailing address

PO BOX 1078
SOUTHAVEN MS
38671
US

V. Phone/Fax

Practice location:
  • Phone: 662-536-2100
  • Fax: 662-536-2211
Mailing address:
  • Phone: 662-536-2100
  • Fax: 662-536-2211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number16532
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number16591
License Number StateMS

VIII. Authorized Official

Name: DR. REMILEKUN SUBEDAT ADESOJI
Title or Position: OWNER
Credential: MD
Phone: 662-536-2100