Healthcare Provider Details

I. General information

NPI: 1255531885
Provider Name (Legal Business Name): FOUNDATION INTERNAL MEDICINE, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2007
Last Update Date: 07/22/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 SOUTHCREST CIR SUITE 207
SOUTHAVEN MS
38671-6726
US

IV. Provider business mailing address

401 SOUTHCREST CIR SUITE 207
SOUTHAVEN MS
38671-6726
US

V. Phone/Fax

Practice location:
  • Phone: 662-349-9292
  • Fax: 662-349-8603
Mailing address:
  • Phone: 662-349-9292
  • Fax: 662-349-8603

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number14060
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number14060
License Number StateMS

VIII. Authorized Official

Name: DR. KENNETH OSITA EDMUNDS
Title or Position: MEDICAL DIRECTOR/PRESIDENT
Credential: MD
Phone: 662-349-9292