Provider Demographics
NPI:1790890499
Name:LEY, PHILLIP BLAINE (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:BLAINE
Last Name:LEY
Suffix:
Gender:M
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:PO BOX 321359
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-1359
Mailing Address - Country:US
Mailing Address - Phone:601-936-1395
Mailing Address - Fax:601-933-6596
Practice Address - Street 1:1020 N FLOWOOD DR STE A
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9532
Practice Address - Country:US
Practice Address - Phone:601-933-6132
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS147862086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS000116599Medicaid
MS000116599Medicaid
MS020038017Medicare PIN
MS020000277Medicare PIN
MS344734YJ9XMedicare PIN