Provider Demographics
NPI:1720213069
Name:REDDIX MEDICAL GROUP
Entity Type:Organization
Organization Name:REDDIX MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:GLORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRENNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-899-3310
Mailing Address - Street 1:5903 RIDGEWOOD RD
Mailing Address - Street 2:SUITE 310
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-3700
Mailing Address - Country:US
Mailing Address - Phone:601-899-3310
Mailing Address - Fax:601-899-3314
Practice Address - Street 1:5903 RIDGEWOOD RD
Practice Address - Street 2:SUITE 310
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-3700
Practice Address - Country:US
Practice Address - Phone:601-899-3310
Practice Address - Fax:601-899-3314
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-15
Last Update Date:2009-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSE11825Medicare UPIN