Provider Demographics
NPI:1821005265
Name:PIERCE, PAUL W IV (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:W
Last Name:PIERCE
Suffix:IV
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 1:4211 BERLIN DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-6016
Mailing Address - Country:US
Mailing Address - Phone:601-613-9597
Mailing Address - Fax:601-984-2631
Practice Address - Street 1:2100 HIGHWAY 61 N
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39183-8211
Practice Address - Country:US
Practice Address - Phone:601-883-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS17287207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS060000818Medicaid
MSP00215144OtherRAILROAD MEDICARE
MS06581329Medicaid
LA1028835Medicaid
AL731-04204OtherBCBS
LA1028835Medicaid
MSP00215144Medicare PIN
MS06581329Medicare PIN
MS512I110082Medicare PIN
MS$$$$$$$$$AOtherBCBS
LA1028835Medicaid