Provider Demographics
NPI:1255531885
Name:FOUNDATION INTERNAL MEDICINE, P.C.
Entity type:Organization
Organization Name:FOUNDATION INTERNAL MEDICINE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:OSITA
Authorized Official - Last Name:EDMUNDS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-349-9292
Mailing Address - Street 1:401 SOUTHCREST CIR
Mailing Address - Street 2:SUITE 207
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-6726
Mailing Address - Country:US
Mailing Address - Phone:662-349-9292
Mailing Address - Fax:662-349-8603
Practice Address - Street 1:401 SOUTHCREST CIR
Practice Address - Street 2:SUITE 207
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-6726
Practice Address - Country:US
Practice Address - Phone:662-349-9292
Practice Address - Fax:662-349-8603
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-22
Last Update Date:2007-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS14060261QM2500X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015617Medicaid
MSF88930Medicare UPIN