MEDICARE: DESOTO FAMILY MEDICAL PRACTICE, P.C.

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

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	512G700011	OTHER	MS	MEDICARE IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1255343273
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DESOTO FAMILY MEDICAL PRACTICE, P.C.

Provider Business Mailing Address
First Line	:	7163 GOODMAN RD
Second Line	:	P. O. BOX 518
City	:	OLIVE BRANCH
State	:	MS
Zip	:	38654-1904
Country	:	US
Telephone Number	:	662-895-3700
Fax Number	:	662-895-4886

Provider Business Practice Location Address
First Line	:	7163 GOODMAN RD
Second Line	:
City	:	OLIVE BRANCH
State	:	MS
Zip	:	38654-1904
Country	:	US
Telephone Number	:	662-895-3700
Fax Number	:	662-895-4886

Authorized Official
Title or Position	:	SECRETARY
Name	:	MRS. KAREN M TATE
Credential	:
Telephone Number	:	662-895-3700

Provider Enumeration Date	:	08/12/2006
Last Update Date	:	11/19/2011

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