=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548688310
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OVATION WOMENS WELLNESS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2014
-----------------------------------------------------
Last Update Date | 08/27/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 111 COLONY CROSSING WAY STE 230
-----------------------------------------------------
City | MADISON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39110-6833
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-326-6401
-----------------------------------------------------
Fax | 601-326-6405
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 3488
-----------------------------------------------------
City | TUPELO
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38803-3488
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-326-6401
-----------------------------------------------------
Fax | 601-326-6405
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATIVE AND HR MANAGER
-----------------------------------------------------
Name | KARLA ANN FORD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 601-714-1031
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207VF0040X
-----------------------------------------------------
Taxonomy Name | Urogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207VG0400X
-----------------------------------------------------
Taxonomy Name | Gynecology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------