=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801884234
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAMUEL D HENSLEY MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/10/2005
-----------------------------------------------------
Last Update Date | 09/20/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2510 LAKELAND DR
-----------------------------------------------------
City | FLOWOOD
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39232-9513
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-355-1234
-----------------------------------------------------
Fax | 601-326-3559
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2510 LAKELAND DR
-----------------------------------------------------
City | FLOWOOD
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39232-9513
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-355-1234
-----------------------------------------------------
Fax | 601-326-3559
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207ZN0500X
-----------------------------------------------------
Taxonomy Name | Neuropathology Physician
-----------------------------------------------------
License Number | 12771
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207ZP0102X
-----------------------------------------------------
Taxonomy Name | Anatomic Pathology & Clinical Pathology Physician
-----------------------------------------------------
License Number | 12771
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------