Provider Demographics
NPI:1841602257
Name:MISSISSIPPI VASCULAR CENTER, PLLC
Entity Type:Organization
Organization Name:MISSISSIPPI VASCULAR CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:TUNDE
Authorized Official - Middle Name:
Authorized Official - Last Name:OLUTADE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-899-3340
Mailing Address - Street 1:PO BOX 2057
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39158-2057
Mailing Address - Country:US
Mailing Address - Phone:601-899-3340
Mailing Address - Fax:601-899-3343
Practice Address - Street 1:571 E BEASLEY RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39206-3042
Practice Address - Country:US
Practice Address - Phone:601-899-3340
Practice Address - Fax:601-899-3343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-20
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty