MEDICARE: NEWSOM HEALTHCARE OF DESOTO COUNTY, 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	261QP2300X	Primary Care Clinic/Center	R852706	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1205243649
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEWSOM HEALTHCARE OF DESOTO COUNTY, LLC

Provider Business Mailing Address
First Line	:	2906 GOODMAN RD W
Second Line	:	SUITE 109
City	:	HORN LAKE
State	:	MS
Zip	:	38637-1291
Country	:	US
Telephone Number	:	662-393-8022
Fax Number	:	662-393-8052

Provider Business Practice Location Address
First Line	:	2906 GOODMAN RD W
Second Line	:	SUITE 109
City	:	HORN LAKE
State	:	MS
Zip	:	38637-1291
Country	:	US
Telephone Number	:	662-393-8022
Fax Number	:	662-393-8052

Authorized Official
Title or Position	:	OWNER/PRESIDENT
Name	:	MRS. SANDRA MATTHEWS NEWSOM
Credential	:	FNP
Telephone Number	:	662-393-8022

Provider Enumeration Date	:	07/17/2014
Last Update Date	:	07/22/2014

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