1518172568 NPI number — MOSS POINT FAMILY CLINIC

Table of content: (NPI 1518172568)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518172568 NPI number — MOSS POINT FAMILY CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOSS POINT FAMILY CLINIC
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:
1518172568
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/22/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5430 GRIFFIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOSS POINT
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39563-2003
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
228-355-0719
Provider Business Mailing Address Fax Number:
228-475-4039

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5430 GRIFFIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOSS POINT
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39563-2003
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
228-355-0719
Provider Business Practice Location Address Fax Number:
228-475-4039
Provider Enumeration Date:
05/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ROSS
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
SIDNEY ROBERT
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
228-355-0719

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  12739 , 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: DG3268 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 1972617884 . This is a "PERSONAL NPI NUMBER FOR M" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 0115091 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01903811 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1710955869 . This is a "PA GRAY'S NPI" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 296723832 . This is a "BCBS" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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