Provider Demographics
NPI:1508426917
Name:MISSISSIPPI CENTER FOR ADVANCED MEDICINE, PC
Entity Type:Organization
Organization Name:MISSISSIPPI CENTER FOR ADVANCED MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SPENCER
Authorized Official - Middle Name:K
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-499-0935
Mailing Address - Street 1:7731 OLD CANTON RD STE B
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-6115
Mailing Address - Country:US
Mailing Address - Phone:601-499-0935
Mailing Address - Fax:601-499-0936
Practice Address - Street 1:2053 GAUSE BLVD E STE 200
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70461-5451
Practice Address - Country:US
Practice Address - Phone:985-259-8045
Practice Address - Fax:601-499-0936
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MISSISSIPPI CENTER FOR ADVANCED MEDICINE, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-06-18
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty