Provider Demographics
NPI:1780694083
Name:BAILEY, TERALD OTIS (MD)
Entity type:Individual
Prefix:
First Name:TERALD
Middle Name:OTIS
Last Name:BAILEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1883 HIGHWAY 43 SOUTH
Mailing Address - Street 2:STE D
Mailing Address - City:CANTON
Mailing Address - State:MS
Mailing Address - Zip Code:39046
Mailing Address - Country:US
Mailing Address - Phone:601-859-8992
Mailing Address - Fax:601-855-5265
Practice Address - Street 1:1883 HIGHWAY 43 SOUTH
Practice Address - Street 2:STE D
Practice Address - City:CANTON
Practice Address - State:MS
Practice Address - Zip Code:39046
Practice Address - Country:US
Practice Address - Phone:601-859-8992
Practice Address - Fax:601-855-5265
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS06976207R00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0123908Medicaid
B31072Medicare UPIN