MEDICARE: MISSISSIPPI MEDICAL ARTS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1043053119
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MISSISSIPPI MEDICAL ARTS LLC

Provider Business Mailing Address
First Line	:	517 CENTER AVE N
Second Line	:
City	:	PHILADELPHIA
State	:	MS
Zip	:	39350-2552
Country	:	US
Telephone Number	:	601-656-5815
Fax Number	:	601-656-8510

Provider Business Practice Location Address
First Line	:	517 CENTER AVE N
Second Line	:
City	:	PHILADELPHIA
State	:	MS
Zip	:	39350-2552
Country	:	US
Telephone Number	:	601-656-5815
Fax Number	:	601-656-8510

Authorized Official
Title or Position	:	OWNER
Name	:	SUNNY SORIANO-PALACIO
Credential	:
Telephone Number	:	601-656-5815

Provider Enumeration Date	:	06/17/2024
Last Update Date	:	06/17/2024

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