Provider Demographics
NPI:1790006674
Name:NORTHWEST MISSISSIPPI OTOLARYNGOLOGY HEAD & NECK SURGERY, LLC
Entity Type:Organization
Organization Name:NORTHWEST MISSISSIPPI OTOLARYNGOLOGY HEAD & NECK SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:JORDAN
Authorized Official - Last Name:CUNNINGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-349-7676
Mailing Address - Street 1:7165 GETWELL RD
Mailing Address - Street 2:BUILDING H, SUITE 1
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38672-9618
Mailing Address - Country:US
Mailing Address - Phone:662-349-7676
Mailing Address - Fax:662-349-7679
Practice Address - Street 1:7165 GETWELL RD
Practice Address - Street 2:BUILDING H, SUITE 1
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38672-9618
Practice Address - Country:US
Practice Address - Phone:662-349-7676
Practice Address - Fax:662-349-7679
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-15
Last Update Date:2010-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSB31032Medicare UPIN