Provider Demographics
NPI:1548424914
Name:NW MISSISSIPPI SPECIALTY CLINIC
Entity Type:Organization
Organization Name:NW MISSISSIPPI SPECIALTY CLINIC
Other - Org Name:SOUTHERN HEALTHCARE PROVIDERS PA
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RODERICK
Authorized Official - Middle Name:
Authorized Official - Last Name:GIVENS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-443-4483
Mailing Address - Street 1:PO BOX 18394
Mailing Address - Street 2:
Mailing Address - City:NATCHEZ
Mailing Address - State:MS
Mailing Address - Zip Code:39122-8394
Mailing Address - Country:US
Mailing Address - Phone:888-670-6080
Mailing Address - Fax:770-443-4410
Practice Address - Street 1:1401 RIVER RD
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:MS
Practice Address - Zip Code:38930-4030
Practice Address - Country:US
Practice Address - Phone:888-670-6080
Practice Address - Fax:770-443-4410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-15
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS149142085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00117509Medicaid
MS920000032Medicare PIN
MSF71973Medicare UPIN