Provider Demographics
NPI:1609041532
Name:BYNUM, STEPHANIE DIANE (MD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:DIANE
Last Name:BYNUM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-579-5400
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:4209 LINCOLN ROAD
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402
Practice Address - Country:US
Practice Address - Phone:601-579-5400
Practice Address - Fax:601-261-3521
Is Sole Proprietor?:No
Enumeration Date:2008-04-22
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS21478207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS3310130OtherUNITED HEALTHCARE
MS02477395Medicaid
MS9540683OtherAETNA
MS6046096OtherHEALTHSPRINGS
MS6046096OtherHEALTHSPRINGS
MS9540683OtherAETNA