Provider Demographics
NPI:1578775573
Name:OTOLARYNGOLOGY ASSOCIATES OF THE MIDSOUTH
Entity Type:Organization
Organization Name:OTOLARYNGOLOGY ASSOCIATES OF THE MIDSOUTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANGELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ISABELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-521-6407
Mailing Address - Street 1:975 SWINNEA RIDGE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671
Mailing Address - Country:US
Mailing Address - Phone:662-349-0448
Mailing Address - Fax:662-349-7984
Practice Address - Street 1:975 SWINNEA RIDGE
Practice Address - Street 2:SUITE 1
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671
Practice Address - Country:US
Practice Address - Phone:662-349-0448
Practice Address - Fax:662-349-7984
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS=========OtherTAX ID