Provider Demographics
NPI:1609035468
Name:INTERNAL MEDICINE GROUP OF THE MIDSOUTH PLLC
Entity Type:Organization
Organization Name:INTERNAL MEDICINE GROUP OF THE MIDSOUTH PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AILEEN
Authorized Official - Middle Name:S
Authorized Official - Last Name:GAYOSO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-536-1520
Mailing Address - Street 1:391 SOUTHCREST CL
Mailing Address - Street 2:210
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671
Mailing Address - Country:US
Mailing Address - Phone:662-536-1520
Mailing Address - Fax:
Practice Address - Street 1:391 SOUTHCREST CL
Practice Address - Street 2:SUITE 210
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671
Practice Address - Country:US
Practice Address - Phone:662-536-1520
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-06
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS15680207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR160334001Medicaid
AR160334001Medicaid
MS110001590Medicare PIN