Healthcare Provider Details

I. General information

NPI: 1861739161
Provider Name (Legal Business Name): KDMC PHYSICIAN CLINICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2013
Last Update Date: 03/27/2023
Certification Date: 03/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 BROOKWAY BLVD
BROOKHAVEN MS
39601-2644
US

IV. Provider business mailing address

427 HIGHWAY 51 N
BROOKHAVEN MS
39601-2350
US

V. Phone/Fax

Practice location:
  • Phone: 601-823-5103
  • Fax: 601-823-3514
Mailing address:
  • Phone: 601-833-6011
  • Fax: 601-823-2206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. SCOTT CHRISTENSEN
Title or Position: CEO
Credential:
Phone: 601-835-9488