Provider Demographics
NPI:1932259355
Name:SOUTHAVEN INTERNAL MEDICINE, P.C.
Entity Type:Organization
Organization Name:SOUTHAVEN INTERNAL MEDICINE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KANDIS
Authorized Official - Middle Name:P
Authorized Official - Last Name:SLEDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-349-1999
Mailing Address - Street 1:7680 AIRWAYS BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-5304
Mailing Address - Country:US
Mailing Address - Phone:662-349-1999
Mailing Address - Fax:662-349-9734
Practice Address - Street 1:7680 AIRWAYS BLVD
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-5304
Practice Address - Country:US
Practice Address - Phone:662-349-1999
Practice Address - Fax:662-349-9734
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2010-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015446Medicaid
CH0508Medicare ID - Type UnspecifiedRAIL ROAD MEDICARE
MS09015446Medicaid
MSC02531Medicare ID - Type UnspecifiedCAHABA