Healthcare Provider Details

I. General information

NPI: 1124459136
Provider Name (Legal Business Name): ST MICHAELS URGENT CARE OF HATTIESBURG
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2013
Last Update Date: 09/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3700 HARDY ST
HATTIESBURG MS
39402-1610
US

IV. Provider business mailing address

3700 HARDY ST
HATTIESBURG MS
39402-1610
US

V. Phone/Fax

Practice location:
  • Phone: 601-602-2014
  • Fax: 601-602-2015
Mailing address:
  • Phone: 601-602-2014
  • Fax: 601-602-2015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR875464
License Number StateMS

VIII. Authorized Official

Name: MARVA JOYCE COOLEY
Title or Position: CREDENTIALLING DIRECTOR
Credential: CPC
Phone: 601-909-2539