Provider Demographics
NPI:1699765818
Name:NEELY, SUSAN JENAY (DO)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:JENAY
Last Name:NEELY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:SUSAN
Other - Middle Name:JENAY
Other - Last Name:NEELY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PLLC
Mailing Address - Street 1:PO BOX 10389
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:38930-0389
Mailing Address - Country:US
Mailing Address - Phone:662-392-8163
Mailing Address - Fax:601-944-9780
Practice Address - Street 1:209 E JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:MS
Practice Address - Zip Code:38930-3649
Practice Address - Country:US
Practice Address - Phone:662-392-8163
Practice Address - Fax:601-944-9780
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-27
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16690207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSP00228400OtherRAILROAD MEDICARE
MS00121561Medicaid
MS01588099Medicaid
MS00121561Medicaid
MS080004054Medicare PIN