Provider Demographics
NPI:1235220112
Name:EAST LAKELAND OB GYN ASSOCIATES, P.A.
Entity Type:Organization
Organization Name:EAST LAKELAND OB GYN ASSOCIATES, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MCMILLAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-936-1400
Mailing Address - Street 1:1020 RIVER OAKS DR
Mailing Address - Street 2:SUITE 320
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39232-9500
Mailing Address - Country:US
Mailing Address - Phone:601-936-1400
Mailing Address - Fax:601-936-0671
Practice Address - Street 1:1020 RIVER OAKS DR
Practice Address - Street 2:SUITE 320
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39232-9500
Practice Address - Country:US
Practice Address - Phone:601-936-1400
Practice Address - Fax:601-936-0671
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS9013604Medicaid
MS=========OtherTAX ID NUMBER
MSC00927Medicare PIN