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General NPI Number Information
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NPI Number | 1891978953
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Entity Type | Organization
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Legal Business Name | DRG FAYETTE PLLC
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Dates
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Enumeration Date | 12/12/2007
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Last Update Date | 01/15/2008
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Provider Practice Location Address
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Address Line | 225 COMMUNITY DRIVE OFF HWY 61
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City | FAYETTE
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State | MS
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Zip | 39069
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Country | US
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Telephone | 601-786-6676
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Fax | 601-786-6678
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Provider Business Mailing Address
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Address Line | 5903 RIDGEWOOD RD SUITE 340
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City | JACKSON
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State | MS
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Zip | 39211-3700
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Country | US
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Telephone | 601-899-3340
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Fax | 601-899-3343
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Authorized Official
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Title or Position | MEMBER
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Name | TUNDE OLUTADE
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Credential |
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Telephone | 601-899-3340
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QE0700X
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Taxonomy Name | End-Stage Renal Disease (ESRD) Treatment Clinic/Center
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License Number |
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License Number State | MS
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