Healthcare Provider Details

I. General information

NPI: 1063786036
Provider Name (Legal Business Name): THE PAIN CLINIC OF MISSISSIPPI, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2012
Last Update Date: 03/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5903 RIDGEWOOD RD SUITE 440
JACKSON MS
39211-3700
US

IV. Provider business mailing address

PO BOX 235019
MONTGOMERY AL
36123-5019
US

V. Phone/Fax

Practice location:
  • Phone: 601-899-3989
  • Fax: 601-899-3504
Mailing address:
  • Phone: 800-232-5703
  • Fax: 334-395-4110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. DUANE WILLIAMSON
Title or Position: PRESIDENT
Credential: M.D.
Phone: 601-899-3989