Provider Demographics
NPI:1942248992
Name:MERIDETH, PHILIP (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:
Last Name:MERIDETH
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 1:2500 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-5815
Mailing Address - Fax:601-984-5842
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-5815
Practice Address - Fax:601-984-5842
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS117512084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0125179Medicaid
MS518661YJ5DMedicare PIN
MSE33998Medicare UPIN
MS260000646Medicare ID - Type Unspecified