Provider Demographics
NPI:1174627459
Name:ANAZIA MEDICAL II, INC.
Entity Type:Organization
Organization Name:ANAZIA MEDICAL II, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:O
Authorized Official - Last Name:ANAZIA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:601-249-0013
Mailing Address - Street 1:120 5TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39648
Mailing Address - Country:US
Mailing Address - Phone:601-249-0013
Mailing Address - Fax:601-249-0592
Practice Address - Street 1:1264 MAIN STREET
Practice Address - Street 2:SUITE A
Practice Address - City:FAYETTE
Practice Address - State:MS
Practice Address - Zip Code:39069
Practice Address - Country:US
Practice Address - Phone:601-786-0390
Practice Address - Fax:601-786-0730
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-08
Last Update Date:2010-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS14997207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07753329Medicaid
MSC03095Medicare ID - Type Unspecified