=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124201892
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROME SHERROD II MD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/17/2007
-----------------------------------------------------
Last Update Date | 06/10/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7600 AIRWAYS BLVD STE B
-----------------------------------------------------
City | SOUTHAVEN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38671-5138
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-349-9370
-----------------------------------------------------
Fax | 662-349-9372
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7600 AIRWAYS BLVD STE B
-----------------------------------------------------
City | SOUTHAVEN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38671-5138
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-349-9370
-----------------------------------------------------
Fax | 662-349-9372
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ROME SHERROD II
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 662-349-9370
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------