Basic Information
| Provider Information | |||||||||
| NPI: | 1417932492 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GASTROENTEROLOGY CENTER OF THE MIDSOUTH PLLC | ||||||||
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| OtherOrganizationName: | GASTROENTEROLOGY ASSOCIATES OF NORTH MISSISSIPPI | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2020 EXETER RD | ||||||||
| Address2: | |||||||||
| City: | GERMANTOWN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381383945 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9017374665 | ||||||||
| FaxNumber: | 9013281351 | ||||||||
| Practice Location | |||||||||
| Address1: | 1310 WOLF PARK DR | ||||||||
| Address2: | |||||||||
| City: | GERMANTOWN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381381741 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9016845503 | ||||||||
| FaxNumber: | 9016845523 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2005 | ||||||||
| LastUpdateDate: | 07/11/2022 | ||||||||
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| AuthorizedOfficialLastName: | ROUSE | ||||||||
| AuthorizedOfficialFirstName: | BOBBY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9016821233 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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| NPICertificationDate: | 07/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
No ID Information.