Provider Demographics
NPI:1568764504
Name:DIABETES AND ENDOCRINE CENTER OF MS
Entity Type:Organization
Organization Name:DIABETES AND ENDOCRINE CENTER OF MS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:
Authorized Official - Last Name:FEWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-292-1228
Mailing Address - Street 1:971 LAKELAND DR
Mailing Address - Street 2:SUITE 450
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4643
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:971 LAKELAND DR
Practice Address - Street 2:SUITE 450
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4643
Practice Address - Country:US
Practice Address - Phone:601-948-5158
Practice Address - Fax:601-326-4265
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-24
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS19640174400000X
MS21031174400000X
MS20965174400000X, 174400000X
207RE0101X
MS07011174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty