1033095617 NPI number — RODGERS MEDICAL CLINIC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033095617 NPI number — RODGERS MEDICAL CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RODGERS MEDICAL CLINIC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033095617
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/05/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13418 ATTALA ROAD 4101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALLIS
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39160-5242
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-613-7835
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
630 NORTHWEST AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DURANT
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39063-3337
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-653-3011
Provider Business Practice Location Address Fax Number:
662-653-6423
Provider Enumeration Date:
08/12/2025

Additional Information

Authorized Official

Authorized Official Last Name:
RODGERS
Authorized Official First Name:
PHILLIP
Authorized Official Middle Name:
ERIC
Authorized Official Title or Position:
NURSE PRACTITIONER
Authorized Official Telephone Number:
601-613-7835

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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