Provider Demographics
NPI:1225232895
Name:HAILEY, LARRY SHEA SHEA (DO)
Entity Type:Individual
Prefix:DR
First Name:LARRY SHEA
Middle Name:SHEA
Last Name:HAILEY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 22ND AVE
Mailing Address - Street 2:MEDICAL TOWERS III
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39301-3223
Mailing Address - Country:US
Mailing Address - Phone:601-483-5322
Mailing Address - Fax:601-581-2289
Practice Address - Street 1:1600 22ND AVE
Practice Address - Street 2:MEDICAL TOWERS III
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-3223
Practice Address - Country:US
Practice Address - Phone:601-483-5322
Practice Address - Fax:601-581-2289
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL8714207RC0000X
MS16351207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06258755Medicaid
MS06258755Medicaid
MS06258755Medicaid
MS512I110218Medicare PIN