1093873713 NPI number — EVERETT C MCKIBBEN MD

Table of content: EVERETT C MCKIBBEN MD (NPI 1093873713)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093873713 NPI number — EVERETT C MCKIBBEN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCKIBBEN
Provider First Name:
EVERETT
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MCKIBBEN
Provider Other First Name:
EVERETT
Provider Other Middle Name:
C
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1093873713
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/22/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
THE LAIRD CLINIC
Provider Second Line Business Mailing Address:
103 DOCTORS PARK
Provider Business Mailing Address City Name:
STARKVILLE
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39759
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-323-2515
Provider Business Mailing Address Fax Number:
662-323-2557

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
THE LAIRD CLINIC
Provider Second Line Business Practice Location Address:
103 DOCTORS PARK
Provider Business Practice Location Address City Name:
STARKVILLE
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39759
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-323-2515
Provider Business Practice Location Address Fax Number:
662-323-2557
Provider Enumeration Date:
12/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X , with the licence number:  12519 , 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: 00110394 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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