1073566550 NPI number — KELLY S SEGARS MD PC

Table of content: (NPI 1073566550)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073566550 NPI number — KELLY S SEGARS MD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KELLY S SEGARS MD PC
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:
THE SEGARS CLINIC
Provider Other Organization Name Type Code:
3
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:
1073566550
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/10/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1507 W QUITMAN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IUKA
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38852-1132
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-423-1000
Provider Business Mailing Address Fax Number:
662-423-1316

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1507 W QUITMAN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IUKA
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38852-1132
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-423-1000
Provider Business Practice Location Address Fax Number:
662-423-1316
Provider Enumeration Date:
05/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MCWILLIAMS
Authorized Official First Name:
MONA
Authorized Official Middle Name:
A
Authorized Official Title or Position:
BILLING MANAGER
Authorized Official Telephone Number:
662-423-1000

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  12314 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 174400000X , with the licence number: 10016 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00017574 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1609871607 . This is a "NPI" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 487623030 . This is a "BCBS" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 587922966 . This is a "BCBS" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 011800024 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 1649429481 . This is a "NPI" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 1750386488 . This is a "NPI" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 5121500528 . This is a "PTAN" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 05989006 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5121500341 . This is a "PTAN" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: P00123795 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 587286250 . This is a "BCBS" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 00013060 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 04426008 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1750387890 . This is a "NPI" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 500001207 . This is a "PTAN" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 03171239 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 080117421 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 418807663 . This is a "BCBS" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 428559600 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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