Provider Demographics
NPI:1740318666
Name:MISSISSIPPI BREAST CENTER PLLC
Entity type:Organization
Organization Name:MISSISSIPPI BREAST CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:HICKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:601-948-1411
Mailing Address - Street 1:1030 N FLOWOOD DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-9532
Mailing Address - Country:US
Mailing Address - Phone:601-932-7465
Mailing Address - Fax:601-932-7425
Practice Address - Street 1:1030 N FLOWOOD DR
Practice Address - Street 2:SUITE C
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9532
Practice Address - Country:US
Practice Address - Phone:601-932-7465
Practice Address - Fax:601-932-7425
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09012031Medicaid
MS09012031Medicaid