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General NPI Number Information
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NPI Number | 1255531885
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Entity Type | Organization
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Legal Business Name | FOUNDATION INTERNAL MEDICINE, P.C.
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Dates
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Enumeration Date | 07/22/2007
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Last Update Date | 07/22/2007
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Provider Practice Location Address
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Address Line | 401 SOUTHCREST CIR SUITE 207
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City | SOUTHAVEN
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State | MS
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Zip | 38671-6726
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Country | US
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Telephone | 662-349-9292
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Fax | 662-349-8603
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Provider Business Mailing Address
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Address Line | 401 SOUTHCREST CIR SUITE 207
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City | SOUTHAVEN
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State | MS
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Zip | 38671-6726
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Country | US
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Telephone | 662-349-9292
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Fax | 662-349-8603
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Authorized Official
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Title or Position | MEDICAL DIRECTOR/PRESIDENT
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Name | DR. KENNETH OSITA EDMUNDS
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Credential | MD
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Telephone | 662-349-9292
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | 14060
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License Number State | MS
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Taxonomy #2
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | 14060
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License Number State | MS
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