Provider Demographics
NPI:1154483394
Name:BEISSEL, CANON JADE (MD)
Entity Type:Individual
Prefix:
First Name:CANON
Middle Name:JADE
Last Name:BEISSEL
Suffix:
Gender:M
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:PO BOX 1041
Mailing Address - Street 2:
Mailing Address - City:GRENADA
Mailing Address - State:MS
Mailing Address - Zip Code:38902-1041
Mailing Address - Country:US
Mailing Address - Phone:662-226-9866
Mailing Address - Fax:662-453-4546
Practice Address - Street 1:35 W MONROE ST
Practice Address - Street 2:
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901-5222
Practice Address - Country:US
Practice Address - Phone:662-226-8229
Practice Address - Fax:662-226-3300
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16518207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06050013Medicaid
MSH90707Medicare UPIN