Healthcare Provider Details

I. General information

NPI: 1487432852
Provider Name (Legal Business Name): MISSISSIPPI UROLOGY CLINIC, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2023
Last Update Date: 09/18/2023
Certification Date: 09/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 RIVER OAKS DR STE 202
FLOWOOD MS
39232-9534
US

IV. Provider business mailing address

501 MARSHALL ST STE 301
JACKSON MS
39202-1687
US

V. Phone/Fax

Practice location:
  • Phone: 601-353-9900
  • Fax: 601-414-5381
Mailing address:
  • Phone: 601-353-9900
  • Fax: 601-353-3654

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State

VIII. Authorized Official

Name: DR. HAROLD JASON BLALOCK
Title or Position: PRESIDENT
Credential: MD
Phone: 601-353-9900