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General NPI Number Information
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NPI Number | 1932259355
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Entity Type | Organization
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Legal Business Name | SOUTHAVEN INTERNAL MEDICINE, P.C.
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Dates
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Enumeration Date | 01/10/2007
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Last Update Date | 06/17/2010
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Provider Practice Location Address
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Address Line | 7680 AIRWAYS BLVD
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City | SOUTHAVEN
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State | MS
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Zip | 38671-5304
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Country | US
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Telephone | 662-349-1999
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Fax | 662-349-9734
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Provider Business Mailing Address
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Address Line | 7680 AIRWAYS BLVD
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City | SOUTHAVEN
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State | MS
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Zip | 38671-5304
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Country | US
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Telephone | 662-349-1999
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Fax | 662-349-9734
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | KANDIS P SLEDGE
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Credential |
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Telephone | 662-349-1999
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State | MS
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