Healthcare Provider Details

I. General information

NPI: 1902175821
Provider Name (Legal Business Name): NORTH MISSISSIPPI MEDICAL CLINICS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2011
Last Update Date: 12/16/2020
Certification Date: 12/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4381 S EASON BLVD STE 301
TUPELO MS
38801-6584
US

IV. Provider business mailing address

4381 S EASON BLVD STE 301
TUPELO MS
38801-6584
US

V. Phone/Fax

Practice location:
  • Phone: 662-377-3008
  • Fax: 662-377-3716
Mailing address:
  • Phone: 662-377-3008
  • Fax: 662-377-3716

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State

VIII. Authorized Official

Name: GERALD KIMBROUGH
Title or Position: DIRECTOR
Credential:
Phone: 662-377-4685