Healthcare Provider Details

I. General information

NPI: 1548297021
Provider Name (Legal Business Name): NORTH MISSISSIPPI MEDICAL CLINICS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 HIGHWAY 15 N
PONTOTOC MS
38863-1105
US

IV. Provider business mailing address

450 E PRESIDENT AVE
TUPELO MS
38801-5599
US

V. Phone/Fax

Practice location:
  • Phone: 662-489-7430
  • Fax: 662-489-7938
Mailing address:
  • Phone: 662-377-4685
  • Fax: 662-377-2755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: GERALD KIMBROUGH
Title or Position: CBO MANAGER
Credential:
Phone: 662-489-7430