Provider Demographics
NPI:1790227627
Name:MISSISSIPPI CENTER FOR ADVANCED MEDICINE, PC
Entity Type:Organization
Organization Name:MISSISSIPPI CENTER FOR ADVANCED MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SPENCER
Authorized Official - Middle Name:K
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-499-0935
Mailing Address - Street 1:7731 OLD CANTON RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-6114
Mailing Address - Country:US
Mailing Address - Phone:601-499-0935
Mailing Address - Fax:601-499-0936
Practice Address - Street 1:7731 OLD CANTON RD
Practice Address - Street 2:SUITE B
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-6114
Practice Address - Country:US
Practice Address - Phone:601-499-0935
Practice Address - Fax:601-499-0936
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-09
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS23304174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01212067Medicaid
MS01212067Medicaid