Healthcare Provider Details

I. General information

NPI: 1508231994
Provider Name (Legal Business Name): VAN WURM MD,PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2015
Last Update Date: 01/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3631 BIENVILLE BLVD SUITE A
OCEAN SPRINGS MS
39564-5702
US

IV. Provider business mailing address

3631 BIENVILLE BLVD SUITE A
OCEAN SPRINGS MS
39564-5702
US

V. Phone/Fax

Practice location:
  • Phone: 228-818-0585
  • Fax: 228-818-0588
Mailing address:
  • Phone: 228-818-0585
  • Fax: 228-818-0588

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number20580
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number20580
License Number StateMS

VIII. Authorized Official

Name: DR. WILLIAM VAN WURM
Title or Position: OWNER
Credential: M.D.
Phone: 228-818-0585