Healthcare Provider Details

I. General information

NPI: 1619084613
Provider Name (Legal Business Name): STARKVILLE INTERNAL MEDICINE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 01/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 BRANDON RD
STARKVILLE MS
39759-2521
US

IV. Provider business mailing address

107 BRANDON RD
STARKVILLE MS
39759-2521
US

V. Phone/Fax

Practice location:
  • Phone: 662-324-1291
  • Fax: 662-324-2196
Mailing address:
  • Phone: 662-324-1291
  • Fax: 662-324-2196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State

VIII. Authorized Official

Name: BENJAMIN F. SANFORD JR.
Title or Position: PRESIDENT
Credential: M.D.
Phone: 662-324-1291