Provider Demographics
NPI:1255504213
Name:STRAUCH, SELLY RAE (MD)
Entity Type:Individual
Prefix:DR
First Name:SELLY
Middle Name:RAE
Last Name:STRAUCH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-1530
Mailing Address - Fax:601-984-1531
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-1530
Practice Address - Fax:601-984-1531
Is Sole Proprietor?:No
Enumeration Date:2008-04-10
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02657507Medicaid
MS02657507Medicaid