Healthcare Provider Details

I. General information

NPI: 1225320708
Provider Name (Legal Business Name): PSP MEDICAL CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2011
Last Update Date: 02/06/2024
Certification Date: 02/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1171 HART ST
CANTON MS
39046-4805
US

IV. Provider business mailing address

PO BOX 607
CANTON MS
39046-0607
US

V. Phone/Fax

Practice location:
  • Phone: 601-859-9888
  • Fax: 601-859-9004
Mailing address:
  • Phone: 662-746-3555
  • Fax: 601-859-9966

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number15405
License Number StateMS

VIII. Authorized Official

Name: DR. PARVESH K. GOEL
Title or Position: MD
Credential: MD
Phone: 662-746-3555