Provider Demographics
NPI:1942344866
Name:MCELROY, GERALDINE
Entity Type:Individual
Prefix:
First Name:GERALDINE
Middle Name:
Last Name:MCELROY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 N UNION ST
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MS
Mailing Address - Zip Code:39046-3730
Mailing Address - Country:US
Mailing Address - Phone:601-859-3316
Mailing Address - Fax:
Practice Address - Street 1:317 N UNION ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MS
Practice Address - Zip Code:39046-3730
Practice Address - Country:US
Practice Address - Phone:601-859-3316
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR626716367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00124250Medicaid
MSQ06397Medicare UPIN