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General NPI Number Information
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NPI Number | 1528074184
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Entity Type | Organization
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Legal Business Name | DESOTO SURGERY CLINIC LLC
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Dates
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Enumeration Date | 08/01/2006
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Last Update Date | 03/14/2008
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Provider Practice Location Address
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Address Line | 7580 CLARINGTON CV
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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 | 662-536-1545
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Fax | 662-536-8220
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Provider Business Mailing Address
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Address Line | 7580 CLARINGTON CV
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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 | 662-536-1545
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Fax | 662-536-8220
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | MICHAEL E FOSTER
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Credential | MD
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Telephone | 662-536-1545
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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