Provider Demographics
NPI:1689456527
Name:LAUDERDALE MEDICAL GROUP PLLC
Entity Type:Organization
Organization Name:LAUDERDALE MEDICAL GROUP PLLC
Other - Org Name:LAUDERDALE MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:LAUDERDALE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:662-489-6041
Mailing Address - Street 1:131 EMBERWOOD CT
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-7861
Mailing Address - Country:US
Mailing Address - Phone:662-419-1260
Mailing Address - Fax:
Practice Address - Street 1:11 E JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:PONTOTOC
Practice Address - State:MS
Practice Address - Zip Code:38863-2807
Practice Address - Country:US
Practice Address - Phone:662-419-1260
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-16
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care