Provider Demographics
NPI:1750547303
Name:AYERS MARTIN ENTERPRISES LLC
Entity type:Organization
Organization Name:AYERS MARTIN ENTERPRISES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:AYERS
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-636-0097
Mailing Address - Street 1:PO BOX 820662
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39182-0662
Mailing Address - Country:US
Mailing Address - Phone:601-636-0097
Mailing Address - Fax:601-629-9969
Practice Address - Street 1:1970 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614-7202
Practice Address - Country:US
Practice Address - Phone:601-636-0097
Practice Address - Fax:601-629-9969
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-04
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS14355207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00115777Medicaid
MS00115777Medicaid