=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134593361
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROBERT C. CLINGAN, MD, DERMATOLOGY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/27/2015
-----------------------------------------------------
Last Update Date | 11/27/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2080 S FRONTAGE RD SUITE 113
-----------------------------------------------------
City | VICKSBURG
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39180-5328
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-636-1658
-----------------------------------------------------
Fax | 601-636-1076
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2080 S FRONTAGE RD SUITE 113
-----------------------------------------------------
City | VICKSBURG
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39180-5328
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-636-1658
-----------------------------------------------------
Fax | 601-636-1076
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PHYSICIAN
-----------------------------------------------------
Name | DR. ROBERT C CLINGAN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 601-636-1658
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number | 13005
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------