Healthcare Provider Details

I. General information

NPI: 1740448653
Provider Name (Legal Business Name): MCCOMB SKIN CLINIC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2008
Last Update Date: 07/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 MARION AVE
MCCOMB MS
39648-3620
US

IV. Provider business mailing address

136 MARION AVE
MCCOMB MS
39648-3620
US

V. Phone/Fax

Practice location:
  • Phone: 601-684-3210
  • Fax: 601-684-3319
Mailing address:
  • Phone: 601-684-3210
  • Fax: 601-684-3319

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number7285
License Number StateMS

VIII. Authorized Official

Name: MRS. LINDA YOUNG BROCK
Title or Position: OFFICE ADMINISTRATOR
Credential:
Phone: 601-684-3210