1003497751 NPI number — SPEARS MEDICAL CLINIC PLLC

Table of content: (NPI 1003497751)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003497751 NPI number — SPEARS MEDICAL CLINIC PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPEARS MEDICAL CLINIC PLLC
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:
1003497751
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/30/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 54
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUMMIT
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39666-0054
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-608-0900
Provider Business Mailing Address Fax Number:
601-600-2171

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
804 ROBB ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUMMIT
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39666-8291
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-608-0900
Provider Business Practice Location Address Fax Number:
601-600-2171
Provider Enumeration Date:
04/15/2021

Additional Information

Authorized Official

Authorized Official Last Name:
SPEARS
Authorized Official First Name:
DAMON
Authorized Official Middle Name:
SCOTT
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
601-600-6522

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 08751030 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1679628697 . This is a "NPPES NPI REGISTRY" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com