Provider Demographics
NPI:1699884528
Name:BROOKHAVEN INTERNAL MEDICINE, P.A.
Entity type:Organization
Organization Name:BROOKHAVEN INTERNAL MEDICINE, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:M
Authorized Official - Last Name:PRICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-835-0507
Mailing Address - Street 1:PO BOX 3730
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:39603-7730
Mailing Address - Country:US
Mailing Address - Phone:601-835-0507
Mailing Address - Fax:601-835-2766
Practice Address - Street 1:527 SILVER CROSS DR
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:MS
Practice Address - Zip Code:39601-2388
Practice Address - Country:US
Practice Address - Phone:601-835-0507
Practice Address - Fax:601-835-2766
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09014373Medicaid
MSC02191Medicare ID - Type Unspecified