Provider Demographics
NPI:1467511691
Name:MID SOUTH OTOLARYNGOLOGY ASSOCIATES P.C.
Entity type:Organization
Organization Name:MID SOUTH OTOLARYNGOLOGY ASSOCIATES P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:MOORE
Authorized Official - Last Name:FISHER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-349-4250
Mailing Address - Street 1:PO BOX 1167
Mailing Address - Street 2:6890 ELMORE RD STE 2
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671
Mailing Address - Country:US
Mailing Address - Phone:662-349-4250
Mailing Address - Fax:662-349-4249
Practice Address - Street 1:6890 ELMORE RD
Practice Address - Street 2:SUITE 2
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-9673
Practice Address - Country:US
Practice Address - Phone:662-349-4250
Practice Address - Fax:662-349-4249
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2010-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS04813207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00018019Medicaid
MSDB8666OtherRAILROAD MEDICARE
MSC00974Medicare PIN
MS00018019Medicaid