Healthcare Provider Details

I. General information

NPI: 1902013584
Provider Name (Legal Business Name): MAGEE AFTER HOURS CLINIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

376 SIMPSON HIGHWAY 149 # A
MAGEE MS
39111-3409
US

IV. Provider business mailing address

376 SIMPSON HIGHWAY 149 # A
MAGEE MS
39111-3409
US

V. Phone/Fax

Practice location:
  • Phone: 601-849-1230
  • Fax: 601-849-1890
Mailing address:
  • Phone: 601-849-1230
  • Fax: 601-849-1890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA024
License Number StateMS

VIII. Authorized Official

Name: DR. CHARLES PRUITT
Title or Position: DOCTOR
Credential: M.D.
Phone: 601-849-1230