Provider Demographics
NPI:1083656870
Name:UNIVERSITY INTERNAL MEDICINE ASSOC LLP
Entity Type:Organization
Organization Name:UNIVERSITY INTERNAL MEDICINE ASSOC LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:DESHAZO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-987-3988
Mailing Address - Street 1:1867 CRANE RIDGE DR
Mailing Address - Street 2:STE 150-A UNIVERSITY INTERNAL MEDICINE ASSOCIATES, LLP
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4982
Mailing Address - Country:US
Mailing Address - Phone:601-987-3988
Mailing Address - Fax:601-987-4165
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:DEPARTMENT OF MEDICINE
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-5600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X
MS207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09012352Medicaid
MS09012352Medicaid