MEDICARE: PHYSICIANS SERVICES GROUP OF MISSISSIPPI, 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	261QM1300X	Multi-Specialty Clinic/Center

General Provider Information

NPI Number	:	1558965384
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHYSICIANS SERVICES GROUP OF MISSISSIPPI, P.C.

Provider Business Mailing Address
First Line	:	3401 MAIN ST STE A
Second Line	:
City	:	MOSS POINT
State	:	MS
Zip	:	39563-5101
Country	:	US
Telephone Number	:	228-471-3169
Fax Number	:	228-471-3170

Provider Business Practice Location Address
First Line	:	3401 MAIN ST STE A
Second Line	:
City	:	MOSS POINT
State	:	MS
Zip	:	39563-5101
Country	:	US
Telephone Number	:	228-471-3169
Fax Number	:	228-471-3170

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DAWN-MICHELE BLALOCK
Credential	:
Telephone Number	:	252-503-9096

Provider Enumeration Date	:	11/23/2020
Last Update Date	:	11/23/2020

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