Provider Demographics
NPI:1720246887
Name:PRUETT, TAYLOR S (MD)
Entity Type:Individual
Prefix:DR
First Name:TAYLOR
Middle Name:S
Last Name:PRUETT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:2550 FLOWOOD DR STE 402
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-9307
Mailing Address - Country:US
Mailing Address - Phone:601-936-1395
Mailing Address - Fax:601-936-1260
Practice Address - Street 1:161 RIVER OAKS DR
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MS
Practice Address - Zip Code:39046
Practice Address - Country:US
Practice Address - Phone:601-376-2832
Practice Address - Fax:601-376-1816
Is Sole Proprietor?:No
Enumeration Date:2008-05-27
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS21099208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL156867Medicaid
MSP01228873OtherRR MEDICARE PTAN
MS05638761Medicaid
MS05638761Medicaid