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General NPI Number Information
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NPI Number | 1689456527
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Entity Type | Organization
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Legal Business Name | LAUDERDALE MEDICAL GROUP PLLC
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Dates
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Enumeration Date | 10/16/2023
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Last Update Date | 03/22/2024
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Provider Practice Location Address
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Address Line | 11 E JEFFERSON ST
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City | PONTOTOC
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State | MS
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Zip | 38863-2807
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Country | US
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Telephone | 662-419-1260
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Fax |
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Provider Business Mailing Address
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Address Line | 131 EMBERWOOD CT
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City | TUPELO
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State | MS
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Zip | 38801-7861
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Country | US
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Telephone | 662-419-1260
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. JESSICA ANNE LAUDERDALE
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Credential | DO
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Telephone | 662-489-6041
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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