=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073566550
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KELLY S SEGARS MD PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/18/2006
-----------------------------------------------------
Last Update Date | 09/10/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1507 W QUITMAN ST
-----------------------------------------------------
City | IUKA
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38852-1132
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-423-1000
-----------------------------------------------------
Fax | 662-423-1316
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1507 W QUITMAN ST
-----------------------------------------------------
City | IUKA
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38852-1132
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-423-1000
-----------------------------------------------------
Fax | 662-423-1316
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING MANAGER
-----------------------------------------------------
Name | MONA A MCWILLIAMS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 662-423-1000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 12314
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 10016
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------