Provider Demographics
NPI:1114184926
Name:CENTER OF INFECTIOUS DISEASE EXCELLENCE LLC
Entity Type:Organization
Organization Name:CENTER OF INFECTIOUS DISEASE EXCELLENCE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:L
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-944-1717
Mailing Address - Street 1:PO BOX 22679
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-2679
Mailing Address - Country:US
Mailing Address - Phone:601-944-1717
Mailing Address - Fax:
Practice Address - Street 1:1040 RIVER OAKS DR
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9530
Practice Address - Country:US
Practice Address - Phone:601-944-1717
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-20
Last Update Date:2008-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS05323207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05680536Medicaid
MS05680536Medicaid