Healthcare Provider Details

I. General information

NPI: 1659307791
Provider Name (Legal Business Name): VICKSBURG CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 11/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 N FRONTAGE RD
VICKSBURG MS
39180-5102
US

IV. Provider business mailing address

1115 N FRONTAGE RD
VICKSBURG MS
39180-5102
US

V. Phone/Fax

Practice location:
  • Phone: 601-634-8790
  • Fax:
Mailing address:
  • Phone: 601-634-8790
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 11
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 12
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number
License Number State
# 13
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: DEBBIE T BREWER
Title or Position: DIRECTOR OF PROVIDER ENROLLMENT
Credential:
Phone: 877-892-9813