Provider Demographics
NPI:1477741494
Name:ANDREW GEORGE
Entity Type:Organization
Organization Name:ANDREW GEORGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:GEORGE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-873-0477
Mailing Address - Street 1:25 S FOURTH ST
Mailing Address - Street 2:
Mailing Address - City:ROLLING FORK
Mailing Address - State:MS
Mailing Address - Zip Code:39159-5146
Mailing Address - Country:US
Mailing Address - Phone:662-873-0477
Mailing Address - Fax:662-873-0742
Practice Address - Street 1:25 S FOURTH ST
Practice Address - Street 2:
Practice Address - City:ROLLING FORK
Practice Address - State:MS
Practice Address - Zip Code:39159-5146
Practice Address - Country:US
Practice Address - Phone:662-873-0477
Practice Address - Fax:662-873-0742
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-04
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13643207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02984093Medicaid
C03468Medicare PIN