1114196664 NPI number — VICKSBURG EMERGENCY PHYSICIANS LLP

Table of content: (NPI 1114196664)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114196664 NPI number — VICKSBURG EMERGENCY PHYSICIANS LLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VICKSBURG EMERGENCY PHYSICIANS LLP
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:
1114196664
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/08/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 60259
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT MYERS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33906-6259
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-916-5259
Provider Business Mailing Address Fax Number:
231-922-4030

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2100 HIGHWAY 61 N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VICKSBURG
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39183-8211
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-833-5000
Provider Business Practice Location Address Fax Number:
601-833-5197
Provider Enumeration Date:
02/28/2008

Additional Information

Authorized Official

Authorized Official Last Name:
KING
Authorized Official First Name:
DERIK
Authorized Official Middle Name:
K.
Authorized Official Title or Position:
LLP, MANAGING PARTNER
Authorized Official Telephone Number:
866-916-5259

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 07183331 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1179779 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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