MEDICARE: MISS LOU HEALTH 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	174400000X	Specialist	18344	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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	595597482	OTHER	MS	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1598707150
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MISS LOU HEALTH LLC

Provider Business Mailing Address
First Line	:	140 JEFFERSON DAVIS BLVD
Second Line	:
City	:	NATCHEZ
State	:	MS
Zip	:	39120-5104
Country	:	US
Telephone Number	:	601-304-9718
Fax Number	:	601-304-9637

Provider Business Practice Location Address
First Line	:	140 JEFFERSON DAVIS BLVD
Second Line	:
City	:	NATCHEZ
State	:	MS
Zip	:	39120-5104
Country	:	US
Telephone Number	:	601-304-9718
Fax Number	:	601-304-9637

Authorized Official
Title or Position	:	DOCTOR
Name	:	MR. VIKRAMADITYA DULAM
Credential	:	M.D.
Telephone Number	:	601-304-9718

Provider Enumeration Date	:	06/11/2006
Last Update Date	:	12/21/2020

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Directions to “MISS LOU HEALTH LLC ” Practice Location

Language	Start Address	Practice Location

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