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General NPI Number Information
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NPI Number | 1497188460
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Entity Type | Organization
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Legal Business Name | VICKSBURG HMA PHYSICIAN MGMT
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Dates
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Enumeration Date | 08/14/2013
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Last Update Date | 08/14/2013
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Provider Practice Location Address
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Address Line | 2080 S FRONTAGE RD STE 100
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City | VICKSBURG
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State | MS
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Zip | 39180-5328
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Country | US
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Telephone | 601-262-1000
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Fax | 601-262-1211
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Provider Business Mailing Address
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Address Line | 2080 S FRONTAGE RD STE 100
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City | VICKSBURG
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State | MS
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Zip | 39180-5328
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Country | US
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Telephone | 601-262-1000
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Fax | 601-262-1211
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Authorized Official
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Title or Position | PRACTICE ADMINISTRATOR
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Name | JOHN H MOORE
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Credential |
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Telephone | 601-262-1000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | R871321
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License Number State | MS
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