Provider Demographics
NPI:1407831928
Name:NORTHEAST MS INTERNAL MEDICINE PC
Entity Type:Organization
Organization Name:NORTHEAST MS INTERNAL MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:LAURENCE
Authorized Official - Middle Name:L
Authorized Official - Last Name:DENNIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-340-1138
Mailing Address - Street 1:202 N 1ST ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:BOONEVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38829-2718
Mailing Address - Country:US
Mailing Address - Phone:662-340-1138
Mailing Address - Fax:662-728-5185
Practice Address - Street 1:202 N 1ST ST
Practice Address - Street 2:SUITE A
Practice Address - City:BOONEVILLE
Practice Address - State:MS
Practice Address - Zip Code:38829-2718
Practice Address - Country:US
Practice Address - Phone:662-340-1138
Practice Address - Fax:662-728-5185
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-07
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08228702Medicaid
MS08228702Medicaid