Healthcare Provider Details

I. General information

NPI: 1902837313
Provider Name (Legal Business Name): MISSISSIPPI UROLOGY CLINIC, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 10/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 MARHSALL ST SUITE 301
JACKSON MS
39202
US

IV. Provider business mailing address

501 MARHSALL ST SUITE 301
JACKSON MS
39202
US

V. Phone/Fax

Practice location:
  • Phone: 601-353-9900
  • Fax: 601-985-3199
Mailing address:
  • Phone: 601-353-9900
  • Fax: 601-985-3199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

Name: JERRY KEMPF POOLE
Title or Position: CHIEF ADMINISTRATIVE OFFICER
Credential: RN, FACHE
Phone: 601-985-3169