Healthcare Provider Details

I. General information

NPI: 1851271159
Provider Name (Legal Business Name): MISSISSIPPI UROLOGY CLINIC, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2025
Last Update Date: 09/05/2025
Certification Date: 09/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1029 RIVER OAKS DR
FLOWOOD MS
39232-9554
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: 601-353-3654
Mailing address:
  • Phone: 601-985-3169
  • 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: HAROLD JASON BLALOCK
Title or Position: PRESIDENT
Credential:
Phone: 601-985-3169