Provider Demographics
NPI:1871883223
Name:MEDSERVE, PA
Entity type:Organization
Organization Name:MEDSERVE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:L
Authorized Official - Last Name:FULCHER
Authorized Official - Suffix:
Authorized Official - Credentials:MD, CMD
Authorized Official - Phone:601-206-0901
Mailing Address - Street 1:200 AMITY LN
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047
Mailing Address - Country:US
Mailing Address - Phone:601-206-0901
Mailing Address - Fax:888-240-6288
Practice Address - Street 1:MANHATTAN NURSING AND REHABILITATION CENTER
Practice Address - Street 2:4540 MANHATTAN RD
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39206
Practice Address - Country:US
Practice Address - Phone:601-206-0901
Practice Address - Fax:888-240-6288
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-19
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS12503207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05675311Medicaid
MS00111649Medicaid