Healthcare Provider Details

I. General information

NPI: 1497098651
Provider Name (Legal Business Name): VINE MEDICAL ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2013
Last Update Date: 04/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 HIGHWAY 61 N
VICKSBURG MS
39183-8211
US

IV. Provider business mailing address

PO BOX 1547
SEDALIA MO
65302-1547
US

V. Phone/Fax

Practice location:
  • Phone: 601-883-5000
  • Fax:
Mailing address:
  • Phone: 660-826-5960
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: OLATUNJI OLUWATADE
Title or Position: CEO
Credential: MD
Phone: 601-883-5000