=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174801377
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OKTIBBEHA UROLOGY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2011
-----------------------------------------------------
Last Update Date | 07/22/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 104 DOCTORS PARK
-----------------------------------------------------
City | STARKVILLE
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39759-2570
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-324-1097
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 104 DOCTORS PARK
-----------------------------------------------------
City | STARKVILLE
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39759-2570
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-324-1097
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | DR. KENNETH RYAN THOMAS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 16623241097
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number | 21408
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------