Provider Demographics
NPI:1780028670
Name:R DEAVER COLLINS MD PA
Entity type:Organization
Organization Name:R DEAVER COLLINS MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:DEAVER
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-353-7090
Mailing Address - Street 1:1190 N STATE ST
Mailing Address - Street 2:SUITE 302
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-2413
Mailing Address - Country:US
Mailing Address - Phone:601-353-7090
Mailing Address - Fax:
Practice Address - Street 1:1190 N STATE ST
Practice Address - Street 2:SUITE 302
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2413
Practice Address - Country:US
Practice Address - Phone:601-353-7090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-22
Last Update Date:2013-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSAC1150414207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSB30490Medicare UPIN