Healthcare Provider Details

I. General information

NPI: 1912088295
Provider Name (Legal Business Name): UROLOGY CLINIC OF MERIDIAN, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 04/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1302 20TH AVE
MERIDIAN MS
39301-4120
US

IV. Provider business mailing address

1302 20TH AVE
MERIDIAN MS
39301-4120
US

V. Phone/Fax

Practice location:
  • Phone: 601-693-1055
  • Fax: 601-482-5312
Mailing address:
  • Phone: 601-693-1055
  • Fax: 601-482-5312

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number11068
License Number StateMS

VIII. Authorized Official

Name: DR. MARK T PHILLIPS
Title or Position: OWNER
Credential: M.D.
Phone: 601-693-1055