Healthcare Provider Details

I. General information

NPI: 1245581370
Provider Name (Legal Business Name): PSP MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2012
Last Update Date: 04/06/2021
Certification Date: 04/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1082A GLUCKSTADT RD
MADISON MS
39110-7243
US

IV. Provider business mailing address

PO BOX 607
CANTON MS
39046
US

V. Phone/Fax

Practice location:
  • Phone: 601-707-5621
  • Fax:
Mailing address:
  • Phone: 601-859-9888
  • Fax: 601-859-9966

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: PARVESH K. GOEL
Title or Position: MD
Credential: MD
Phone: 601-707-5621