Provider Demographics
NPI:1396894234
Name:SOUTHWEST MS NEPHROLOGY, PLLC
Entity type:Organization
Organization Name:SOUTHWEST MS NEPHROLOGY, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:ERIC
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-405-1593
Mailing Address - Street 1:513C BROOKMAN DR
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:39601-2326
Mailing Address - Country:US
Mailing Address - Phone:601-833-3822
Mailing Address - Fax:601-835-4330
Practice Address - Street 1:513C BROOKMAN DR
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:MS
Practice Address - Zip Code:39601-2326
Practice Address - Country:US
Practice Address - Phone:601-833-3822
Practice Address - Fax:601-835-4330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08059229Medicaid
MSB2993Medicare UPIN
MSC02886Medicare ID - Type UnspecifiedSOUTHWEST MS NEPHROLOGY
MS08059229Medicaid
MSH36951Medicare UPIN