1801447693 NPI number — MILESTONE PRIMARY CARE HOUSE CALLS, LLC

Table of content: MRS. ANN MARIE ANCRUM CADC (NPI 1700620994)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801447693 NPI number — MILESTONE PRIMARY CARE HOUSE CALLS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MILESTONE PRIMARY CARE HOUSE CALLS, 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:
1801447693
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/24/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5260 CEDAR PARK DR STE E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39206-4131
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5260 CEDAR PARK DR STE E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39206-4131
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-540-8260
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/24/2019

Additional Information

Authorized Official

Authorized Official Last Name:
WALTERS
Authorized Official First Name:
CASSANDRA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
601-540-8260

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 07935206 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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