1124649678 NPI number — CLAY COUNTY MEDICAL CORPORATION

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124649678 NPI number — CLAY COUNTY MEDICAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLAY COUNTY MEDICAL CORPORATION
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:
NORTH MISSISSIPPI UROLOGY
Provider Other Organization Name Type Code:
3
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:
1124649678
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/19/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
808 VARSITY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TUPELO
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38801-4613
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-377-3204
Provider Business Mailing Address Fax Number:
662-377-2057

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 WILBURN WAY STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STARKVILLE
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39759-3692
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-498-1400
Provider Business Practice Location Address Fax Number:
662-498-1407
Provider Enumeration Date:
05/06/2020

Additional Information

Authorized Official

Authorized Official Last Name:
TOPPIN
Authorized Official First Name:
BRUCE
Authorized Official Middle Name:
Authorized Official Title or Position:
LEGAL SECRETARY
Authorized Official Telephone Number:
662-377-3000

Provider Taxonomy Codes

  • Taxonomy code: 208800000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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