Provider Demographics
NPI:1649249426
Name:HEADLEY, MASSIE H (MD)
Entity type:Individual
Prefix:
First Name:MASSIE
Middle Name:H
Last Name:HEADLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:965 RIDGE LAKE BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9446
Mailing Address - Country:US
Mailing Address - Phone:901-227-3255
Mailing Address - Fax:901-227-8591
Practice Address - Street 1:6250 OLD CANTON RD
Practice Address - Street 2:SUITE 100
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-2946
Practice Address - Country:US
Practice Address - Phone:601-957-1015
Practice Address - Fax:601-956-9721
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2018-03-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MS14432207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08588008Medicaid
MS$$$$$$$$$FOtherBCBS - CLINTON
MS$$$$$$$$$EOtherBCBS
MS753068151OtherMS PHYSICIANS CARE NETWOR
MS753068151Other1ST CHOICE
MS753068151003OtherTRICARE
MS168390701OtherUS DEPT OF LABOR
MS08588008Medicaid
MSP00081330OtherRR MEDICARE
MS$$$$$$$$$GOtherBCBS - MADISON
MS5876475OtherAETNA
MS753068151OtherMS HEALTH PARTNERS
MS753068151003OtherTRICARE
MS80003804Medicare ID - Type Unspecified