Healthcare Provider Details

I. General information

NPI: 1245600923
Provider Name (Legal Business Name): ELSHEIKH MAMOUN ELSHEIKH ABDELRAHIM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2015
Last Update Date: 07/11/2024
Certification Date: 07/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

499 GLOSTER CREEK VLG STE A2
TUPELO MS
38801-4749
US

IV. Provider business mailing address

808 VARSITY DR
TUPELO MS
38801-4613
US

V. Phone/Fax

Practice location:
  • Phone: 662-620-6800
  • Fax:
Mailing address:
  • Phone: 662-377-3204
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number31992
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: