1669575627 NPI number — MINOR MED CARE, P.A.

Table of content: (NPI 1669575627)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669575627 NPI number — MINOR MED CARE, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MINOR MED CARE, P.A.
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:
1669575627
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1223
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RAYMOND
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39154-1223
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-857-2341
Provider Business Mailing Address Fax Number:
601-373-3004

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 W MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RAYMOND
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39154-1223
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-372-1117
Provider Business Practice Location Address Fax Number:
601-373-3004
Provider Enumeration Date:
09/06/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ESTES
Authorized Official First Name:
TIMOTHY
Authorized Official Middle Name:
DUNCAN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
601-372-1117

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X , with the licence number:  09740 , 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)