MEDICARE: DUDLEY MEDICAL SERVICES, 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	:	1760934707
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DUDLEY MEDICAL SERVICES, LLC

Provider Business Mailing Address
First Line	:	1116 FOREST AVE
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39206-3216
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1116 FOREST AVE
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39206-3216
Country	:	US
Telephone Number	:	601-213-7681
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SHINITA DUDLEY
Credential	:	MD
Telephone Number	:	601-213-7681

Provider Enumeration Date	:	10/25/2016
Last Update Date	:	10/25/2016

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Directions to “DUDLEY MEDICAL SERVICES, LLC ” Practice Location

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