Provider Demographics
NPI:1336320795
Name:ORAL PATHOLOGY SERVICES-UMC
Entity Type:Organization
Organization Name:ORAL PATHOLOGY SERVICES-UMC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER, BUSINESS OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:
Authorized Official - Last Name:BROOKERD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-984-6094
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:601-984-6194
Mailing Address - Fax:601-815-3901
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:601-984-6194
Practice Address - Fax:601-815-3901
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UNIVERSITY DENTISTS, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-14
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes292200000XLaboratoriesDental Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09014021Medicaid