Provider Demographics
NPI:1063491843
Name:MED-SOUTH, INC.
Entity Type:Organization
Organization Name:MED-SOUTH, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TROY
Authorized Official - Middle Name:TODD
Authorized Official - Last Name:KESTENBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-933-8400
Mailing Address - Street 1:PO BOX 1277
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39215-1277
Mailing Address - Country:US
Mailing Address - Phone:601-933-8400
Mailing Address - Fax:601-933-1103
Practice Address - Street 1:7048 OLD CANTON RD STE 220
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-1021
Practice Address - Country:US
Practice Address - Phone:601-933-8400
Practice Address - Fax:601-933-1103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-11
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS04720/11.1332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00440069Medicaid
MS00440069Medicaid