Provider Demographics
NPI:1558588509
Name:DR SUSAN JENAY NEELY PLLC
Entity Type:Organization
Organization Name:DR SUSAN JENAY NEELY PLLC
Other - Org Name:THE CARROLLTON CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:JENAY
Authorized Official - Last Name:NEELY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:662-237-4525
Mailing Address - Street 1:PO BOX 220
Mailing Address - Street 2:
Mailing Address - City:NORTH CARROLLTON
Mailing Address - State:MS
Mailing Address - Zip Code:38947-0220
Mailing Address - Country:US
Mailing Address - Phone:662-237-4525
Mailing Address - Fax:662-237-9781
Practice Address - Street 1:502 GEORGE ST
Practice Address - Street 2:
Practice Address - City:NORTH CARROLLTON
Practice Address - State:MS
Practice Address - Zip Code:38947-0220
Practice Address - Country:US
Practice Address - Phone:662-237-4525
Practice Address - Fax:662-237-9781
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01588099Medicaid
MS00121561Medicaid
MS426493934AOtherBLUE CROSS BLUE SHIELD
MSP00228400OtherRAILROAD MEDICARE
MS426493934AOtherBLUE CROSS BLUE SHIELD
MS512G700088Medicare UPIN