| NPI | 1245872514 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | TIMOTHY WAYNE BODEN Executive Director 662-256-9331 |
| Organization Subpart ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics |
| Additional Taxonomies | 207R00000X Internal Medicine |
| Enumeration Date | 2019-10-08 |
| Last Update Date | 2019-10-08 |