1063786036 NPI number — THE PAIN CLINIC OF MISSISSIPPI, PLLC

Table of content: (NPI 1063786036)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063786036 NPI number — THE PAIN CLINIC OF MISSISSIPPI, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE PAIN CLINIC OF MISSISSIPPI, 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:
1063786036
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/08/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 235019
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONTGOMERY
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36123-5019
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-232-5703
Provider Business Mailing Address Fax Number:
334-395-4110

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5903 RIDGEWOOD RD
Provider Second Line Business Practice Location Address:
SUITE 440
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39211-3700
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-899-3989
Provider Business Practice Location Address Fax Number:
601-899-3504
Provider Enumeration Date:
03/08/2012

Additional Information

Authorized Official

Authorized Official Last Name:
WILLIAMSON
Authorized Official First Name:
DUANE
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
601-899-3989

Provider Taxonomy Codes

  • Taxonomy code: 208VP0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com