| NPI | 1154521466 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | ROGER BLAKE Owner/Physician 662-846-8880 |
| Organization Subpart ? | No |
| Primary Taxonomy | 2086S0102X Surgery Surgical Critical Care (Licence: MS 16881) |
| Additional Taxonomies | 208600000X Surgery (Licence: MS 16881) |
| Enumeration Date | 2007-07-24 |
| Last Update Date | 2020-08-30 |