Provider Demographics
NPI:1396134151
Name:S&K MEDICAL,LLC
Entity type:Organization
Organization Name:S&K MEDICAL,LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:FERGUSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-942-6902
Mailing Address - Street 1:5885 AIRLINE RD UNIT 962
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TN
Mailing Address - Zip Code:38002-5121
Mailing Address - Country:US
Mailing Address - Phone:901-317-7427
Mailing Address - Fax:901-317-7585
Practice Address - Street 1:2085 GOODMAN RD W
Practice Address - Street 2:
Practice Address - City:HORN LAKE
Practice Address - State:MS
Practice Address - Zip Code:38637-1416
Practice Address - Country:US
Practice Address - Phone:662-253-8459
Practice Address - Fax:662-253-8678
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-16
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS402989Medicare PIN