=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376647453
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GENERAL VASCULAR SURGERY SPECIALIST P A
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2006
-----------------------------------------------------
Last Update Date | 01/13/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1311 ASTON AVENUE
-----------------------------------------------------
City | MCCOMB
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39648-2825
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-684-2481
-----------------------------------------------------
Fax | 601-684-2488
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1311 ASTON AVE
-----------------------------------------------------
City | MCCOMB
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39648-2825
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-684-2481
-----------------------------------------------------
Fax | 601-684-2488
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | STEVEN CHARLES WILLIAMS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 601-684-2481
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 09423
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------