Provider Demographics
NPI:1699946202
Name:MIDSOUTH NEURO BEHAVIORAL ASSOCIATES
Entity type:Organization
Organization Name:MIDSOUTH NEURO BEHAVIORAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-328-5949
Mailing Address - Street 1:519 ALABAMA ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39702-5305
Mailing Address - Country:US
Mailing Address - Phone:662-328-5949
Mailing Address - Fax:
Practice Address - Street 1:519 ALABAMA ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39702-5305
Practice Address - Country:US
Practice Address - Phone:662-328-5949
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-22
Last Update Date:2008-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty