Basic Information
| Provider Information | |||||||||
| NPI: | 1841679636 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SIVILS | ||||||||
| FirstName: | COREY | ||||||||
| MiddleName: | WAYNE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2500 N STATE ST | ||||||||
| Address2: | DEPARTMENT OF MEDICINE | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392164500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019845601 | ||||||||
| FaxNumber: | 6019846601 | ||||||||
| Practice Location | |||||||||
| Address1: | 2500 N STATE ST | ||||||||
| Address2: | DEPARTMENT OF MEDICINE | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392164500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019845601 | ||||||||
| FaxNumber: | 6019846601 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2015 | ||||||||
| LastUpdateDate: | 09/15/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 28818 | MS | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 08673870 | 05 | MS | MEDICAID |