1295493682 NPI number — INDIAN SPRINGS MEDICAL CLINIC LLC

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 1295493682 NPI number — INDIAN SPRINGS MEDICAL CLINIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INDIAN SPRINGS MEDICAL CLINIC LLC
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:
1295493682
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/02/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
41 S HALL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MORTON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39117-8057
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-782-9997
Provider Business Mailing Address Fax Number:
601-782-5655

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
517 CENTER AVE N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39350-2552
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-656-1440
Provider Business Practice Location Address Fax Number:
601-782-5655
Provider Enumeration Date:
12/02/2021

Additional Information

Authorized Official

Authorized Official Last Name:
CUMBERLAND
Authorized Official First Name:
ADAM
Authorized Official Middle Name:
JERRID
Authorized Official Title or Position:
OPERATIONS MANAGER
Authorized Official Telephone Number:
601-782-9997

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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