1891171351 NPI number — PRIME URGENT MEDICAL CLINIC

Table of content: (NPI 1891171351)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891171351 NPI number — PRIME URGENT MEDICAL CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRIME URGENT MEDICAL CLINIC
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:
6
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:
1891171351
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/10/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1019 GOVERNMENT ST
Provider Second Line Business Mailing Address:
SUITE F
Provider Business Mailing Address City Name:
OCEAN SPRINGS
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39564-3860
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
288-447-3823
Provider Business Mailing Address Fax Number:
228-447-3812

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
176 GOODMAN RD W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTHAVEN
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38671-9405
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-510-6981
Provider Business Practice Location Address Fax Number:
662-510-6987
Provider Enumeration Date:
08/07/2015

Additional Information

Authorized Official

Authorized Official Last Name:
LEVI
Authorized Official First Name:
CLARK
Authorized Official Middle Name:
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
228-447-3823

Provider Taxonomy Codes

  • Taxonomy code: 3336C0002X , with the licence number:  14440 , 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: 2153376 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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