Provider Demographics
NPI:1093002743
Name:COLLINS, ANDREA JEMAE (MD)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:JEMAE
Last Name:COLLINS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:960 AVENT DR
Mailing Address - Street 2:
Mailing Address - City:GRENADA
Mailing Address - State:MS
Mailing Address - Zip Code:38901-5230
Mailing Address - Country:US
Mailing Address - Phone:662-227-7008
Mailing Address - Fax:
Practice Address - Street 1:960 AVENT DR
Practice Address - Street 2:
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901-5230
Practice Address - Country:US
Practice Address - Phone:662-227-7008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-01
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MST-2417207Q00000X
MS22307208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00028386Medicaid
MSP01764009OtherRAILROAD MEDICARE PTAN
MS262782YWZ1Medicare PIN