1295493682 NPI number — INDIAN SPRINGS MEDICAL CLINIC LLC

Table of content: (NPI 1295493682)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295493682 NPI number — INDIAN SPRINGS MEDICAL CLINIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INDIAN SPRINGS MEDICAL CLINIC LLC
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:
1295493682
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/02/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
41 S HALL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MORTON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39117-8057
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-782-9997
Provider Business Mailing Address Fax Number:
601-782-5655

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
517 CENTER AVE N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39350-2552
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-656-1440
Provider Business Practice Location Address Fax Number:
601-782-5655
Provider Enumeration Date:
12/02/2021

Additional Information

Authorized Official

Authorized Official Last Name:
CUMBERLAND
Authorized Official First Name:
ADAM
Authorized Official Middle Name:
JERRID
Authorized Official Title or Position:
OPERATIONS MANAGER
Authorized Official Telephone Number:
601-782-9997

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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