Provider Demographics
NPI:1235329020
Name:CENTER OF INFECTIOUS DISEASE EXCELLENCE
Entity Type:Organization
Organization Name:CENTER OF INFECTIOUS DISEASE EXCELLENCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGIONAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:SINCLAIR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-936-3102
Mailing Address - Street 1:1040 RIVER OAKS DR
Mailing Address - Street 2:SUITE 303
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39232-9530
Mailing Address - Country:US
Mailing Address - Phone:601-936-0706
Mailing Address - Fax:601-936-6150
Practice Address - Street 1:1040 RIVER OAKS DR
Practice Address - Street 2:SUITE 303
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39232-9530
Practice Address - Country:US
Practice Address - Phone:601-936-0706
Practice Address - Fax:601-936-6150
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RIVER OAKS MANAGEMENT COMPANY, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-07-27
Last Update Date:2007-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSC02454Medicare PIN