=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073600409
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MCCOMB UROLOGY CLINIC, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/06/2006
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 RAWLS DR STE 1000
-----------------------------------------------------
City | MCCOMB
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39648-2861
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-684-1261
-----------------------------------------------------
Fax | 601-684-3649
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 300 RAWLS DR STE 1000
-----------------------------------------------------
City | MCCOMB
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39648-2861
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-684-1261
-----------------------------------------------------
Fax | 601-684-3649
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JOSE BENJAMIN SIMO
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 601-684-1261
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 7944
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------