| Progressive Physicians Practice | |
|
8412 Airways Blvd Southaven MS 38671-5140 | |
| (662) 536-2100 | |
| (662) 536-2211 |
| Full Name | Progressive Physicians Practice |
|---|---|
| Speciality | Internal Medicine |
| Location | 8412 Airways Blvd, Southaven, Mississippi |
| Authorized Official Name and Position | Remilekun Subedat Adesoji (OWNER) |
| Authorized Official Contact | 6625362100 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Progressive Physicians Practice Po Box 1078 Southaven MS 38671 Ph: (662) 536-2100 | Progressive Physicians Practice 8412 Airways Blvd Southaven MS 38671-5140 Ph: (662) 536-2100 |
| NPI Number | 1982783619 |
|---|---|
| Provider Enumeration Date | 11/03/2006 |
| Last Update Date | 11/04/2010 |
| Medicare PECOS PAC ID | 9931176179 |
|---|---|
| Medicare Enrollment ID | O20040915001247 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1982783619 | NPI | - | NPPES |
| 01724394 | Medicaid | MS |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207R00000X | Internal Medicine | 16532 (Mississippi) | Primary |
| 208000000X | Pediatrics | 16591 (Mississippi) | Secondary |
| Provider Name | Gafar Ajani Adesoji |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1861414708 PECOS PAC ID: 3971544511 Enrollment ID: I20050513000493 |
| Provider Name | Remilekun Subedat Adesoji |
|---|---|
| Provider Type | Practitioner - Pediatric Medicine |
| Provider Identifiers | NPI Number: 1043232986 PECOS PAC ID: 0244419646 Enrollment ID: I20110223000650 |
| Provider Name | Domecia Michelle Newmon |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1043752009 PECOS PAC ID: 4183907967 Enrollment ID: I20170202001331 |
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