Healthcare Provider Details

I. General information

NPI: 1417949058
Provider Name (Legal Business Name): HIGHWAY 15 MEDICAL CLINIC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 HIGHWAY 15 S
NEW ALBANY MS
38652-5225
US

IV. Provider business mailing address

124 HIGHWAY 15 S
NEW ALBANY MS
38652-5225
US

V. Phone/Fax

Practice location:
  • Phone: 662-534-4706
  • Fax: 662-534-8065
Mailing address:
  • Phone: 662-534-4706
  • Fax: 662-534-8065

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JAMES LEE THORNTON III
Title or Position: PRESIDENT
Credential: M.D.
Phone: 662-534-4706