Provider Demographics
NPI:1700921293
Name:MISSISSIPPI COUNTY SURGICAL ASSN
Entity Type:Organization
Organization Name:MISSISSIPPI COUNTY SURGICAL ASSN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:FERGUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:870-762-1208
Mailing Address - Street 1:PO BOX 186
Mailing Address - Street 2:
Mailing Address - City:BLYTHEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72316-0186
Mailing Address - Country:US
Mailing Address - Phone:870-762-1208
Mailing Address - Fax:870-762-6588
Practice Address - Street 1:1100 MEDICAL DR STE D
Practice Address - Street 2:
Practice Address - City:BLYTHEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72315-2437
Practice Address - Country:US
Practice Address - Phone:870-762-1208
Practice Address - Fax:870-762-6588
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC4476208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR57329Medicare ID - Type UnspecifiedMEDICARE