Provider Demographics
NPI:1740636786
Name:MISSISSIPPI CENTER FOR ADVANCED MEDICINE PC
Entity type:Organization
Organization Name:MISSISSIPPI CENTER FOR ADVANCED MEDICINE PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:SPENCER
Authorized Official - Middle Name:
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-863-9764
Mailing Address - Street 1:7731 OLD CANTON RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-6114
Mailing Address - Country:US
Mailing Address - Phone:601-499-0935
Mailing Address - Fax:601-499-0936
Practice Address - Street 1:7731 OLD CANTON RD STE B
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-6115
Practice Address - Country:US
Practice Address - Phone:601-499-0935
Practice Address - Fax:601-499-0936
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-09
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0002X
MS14837/1.13336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacyGroup - Single Specialty
No3336C0002XSuppliersPharmacyClinic PharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
2160699OtherPK
MS09587750Medicaid