Provider Demographics
NPI:1982783619
Name:PROGRESSIVE PHYSICIANS PRACTICE
Entity Type:Organization
Organization Name:PROGRESSIVE PHYSICIANS PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:REMILEKUN
Authorized Official - Middle Name:SUBEDAT
Authorized Official - Last Name:ADESOJI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-536-2100
Mailing Address - Street 1:PO BOX 1078
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671
Mailing Address - Country:US
Mailing Address - Phone:662-536-2100
Mailing Address - Fax:662-536-2211
Practice Address - Street 1:8412 AIRWAYS BLVD
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-5140
Practice Address - Country:US
Practice Address - Phone:662-536-2100
Practice Address - Fax:662-536-2211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16532207R00000X
MS16591208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01724394Medicaid
MSC02832Medicare PIN