Provider Demographics
| NPI: | 1538200209 |
|---|---|
| Name: | WESLEY PHYSICIAN SERVICES LLC |
| Entity type: | Organization |
| Organization Name: | WESLEY PHYSICIAN SERVICES LLC |
| Other - Org Name: | |
| Other - Org Type: | |
| Authorized Official - Title/Position: | SENIOR DIRECTOR PROVIDER ENROLLMENT |
| Authorized Official - Prefix: | |
| Authorized Official - First Name: | JENNIFER |
| Authorized Official - Middle Name: | L |
| Authorized Official - Last Name: | JACKSON |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 615-465-7000 |
| Mailing Address - Street 1: | PO BOX 689022 |
| Mailing Address - Street 2: | |
| Mailing Address - City: | FRANKLIN |
| Mailing Address - State: | TN |
| Mailing Address - Zip Code: | 37068-9022 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 615-465-7361 |
| Mailing Address - Fax: | 615-628-6877 |
| Practice Address - Street 1: | 5001 HARDY ST |
| Practice Address - Street 2: | |
| Practice Address - City: | HATTIESBURG |
| Practice Address - State: | MS |
| Practice Address - Zip Code: | 39402-1308 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 601-268-8155 |
| Practice Address - Fax: | 601-261-0508 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2007-02-08 |
| Last Update Date: | 2022-06-03 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
| No | 101YP2500X | Behavioral Health & Social Service Providers | Counselor | Professional | Group - Multi-Specialty |
| No | 103T00000X | Behavioral Health & Social Service Providers | Psychologist | Group - Multi-Specialty | |
| No | 104100000X | Behavioral Health & Social Service Providers | Social Worker | Group - Multi-Specialty | |
| No | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical | Group - Multi-Specialty |
| No | 207QA0401X | Allopathic & Osteopathic Physicians | Family Medicine | Addiction Medicine | Group - Multi-Specialty |
| No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
| No | 207RC0000X | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | Group - Multi-Specialty |
| No | 207RI0011X | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | Group - Multi-Specialty |
| No | 207T00000X | Allopathic & Osteopathic Physicians | Neurological Surgery | Group - Multi-Specialty | |
| No | 207UN0901X | Allopathic & Osteopathic Physicians | Nuclear Medicine | Nuclear Cardiology | Group - Multi-Specialty |
| No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
| No | 2080A0000X | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine | Group - Multi-Specialty |
| No | 2084F0202X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Forensic Psychiatry | Group - Multi-Specialty |
| No | 208G00000X | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| MS | 06476518 | Medicaid | |
| MS | 01726273 | Medicaid | |
| MS | 02639565 | Medicaid | |
| MS | 02706278 | Medicaid | |
| MS | 08883556 | Medicaid | |
| MS | 02606764 | Medicaid | |
| MS | 06827312 | Medicaid | |
| MS | 07236720 | Medicaid | |
| MS | 09776308 | Medicaid | |
| MS | 05925779 | Medicaid | |
| MS | 03277572 | Medicaid | |
| MS | 04727870 | Medicaid | |
| MS | 01505019 | Medicaid | |
| MS | 08955318 | Medicaid | |
| MS | 01080271 | Medicaid | |
| MS | 07687071 | Medicaid | |
| MS | 09236762 | Medicaid | |
| MS | 03277572 | Medicaid |
