Provider Demographics
NPI:1144817115
Name:FAIRLEY, JOSEPH MATTHEW SR
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:MATTHEW
Last Name:FAIRLEY
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1466 KRISTEN DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-2115
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1466 KRISTEN DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-2115
Practice Address - Country:US
Practice Address - Phone:601-497-4757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-24
Last Update Date:2020-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS800718433Medicaid
MS80078433Medicaid