Healthcare Provider Details

I. General information

NPI: 1093402240
Provider Name (Legal Business Name): NORTH MISSISSIPPI MEDICAL CLINICS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2023
Last Update Date: 04/19/2023
Certification Date: 04/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2633 LAWNDALE DR
TUPELO MS
38801-6709
US

IV. Provider business mailing address

808 VARSITY DR
TUPELO MS
38801-4613
US

V. Phone/Fax

Practice location:
  • Phone: 662-377-4665
  • Fax: 662-377-4709
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: GERALD KIMBROUGH
Title or Position: MANAGER
Credential:
Phone: 662-377-5201