1639437411 NPI number — BIENVILLE MEDICAL CLINIC, PLLC

Table of content: (NPI 1639437411)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639437411 NPI number — BIENVILLE MEDICAL CLINIC, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BIENVILLE MEDICAL CLINIC, 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:
6
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:
1639437411
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/26/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11 DOCTORS DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OCEAN SPRINGS
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39564-5709
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
228-266-2208
Provider Business Mailing Address Fax Number:
228-875-1335

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11 DOCTORS DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OCEAN SPRINGS
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39564-5709
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
228-266-2208
Provider Business Practice Location Address Fax Number:
228-875-1335
Provider Enumeration Date:
04/30/2012

Additional Information

Authorized Official

Authorized Official Last Name:
STRIEGEL
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OWNER/PRESIDENT - SOLE PROPRIETOR
Authorized Official Telephone Number:
228-266-2208

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  10164 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 07136551 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10164 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 1639437411 . This is a "BILLING NPI" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 00012035 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1205947843 . This is a "TYPE 1-INDIVIDUAL NPI" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 25D0319779 . This is a "CLIA NUMBER" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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