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General NPI Number Information
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NPI Number | 1467511691
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Entity Type | Organization
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Legal Business Name | MID SOUTH OTOLARYNGOLOGY ASSOCIATES P.C.
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Dates
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Enumeration Date | 12/06/2006
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Last Update Date | 10/22/2010
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Provider Practice Location Address
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Address Line | 6890 ELMORE RD SUITE 2
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City | SOUTHAVEN
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State | MS
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Zip | 38671-9673
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Country | US
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Telephone | 662-349-4250
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Fax | 662-349-4249
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Provider Business Mailing Address
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Address Line | PO BOX 1167 6890 ELMORE RD STE 2
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City | SOUTHAVEN
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State | MS
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Zip | 38671
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Country | US
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Telephone | 662-349-4250
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Fax | 662-349-4249
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Authorized Official
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Title or Position | OWNER
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Name | ROBERT MOORE FISHER
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Credential | MD
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Telephone | 662-349-4250
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Y00000X
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Taxonomy Name | Otolaryngology Physician
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License Number | 04813
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License Number State | MS
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