1497852602 NPI number — MEDICAL PLAZA ON ALCORN LLC

Table of content: (NPI 1497852602)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497852602 NPI number — MEDICAL PLAZA ON ALCORN LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDICAL PLAZA ON ALCORN 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:
1497852602
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/01/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
111 ALCORN DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORINTH
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38834-9359
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-286-6991
Provider Business Mailing Address Fax Number:
662-287-8087

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 ALCORN DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORINTH
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38834-9359
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-286-6991
Provider Business Practice Location Address Fax Number:
662-287-8087
Provider Enumeration Date:
09/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
QUINN
Authorized Official First Name:
RICK
Authorized Official Middle Name:
W
Authorized Official Title or Position:
RPH
Authorized Official Telephone Number:
662-286-6991

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  0313501.1 , 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: 00440678 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00095265 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com