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General NPI Number Information
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NPI Number | 1740448653
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Entity Type | Organization
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Legal Business Name | MCCOMB SKIN CLINIC PA
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Dates
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Enumeration Date | 05/28/2008
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Last Update Date | 07/01/2008
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Provider Practice Location Address
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Address Line | 136 MARION AVE
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City | MCCOMB
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State | MS
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Zip | 39648-3620
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Country | US
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Telephone | 601-684-3210
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Fax | 601-684-3319
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Provider Business Mailing Address
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Address Line | 136 MARION AVE
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City | MCCOMB
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State | MS
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Zip | 39648-3620
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Country | US
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Telephone | 601-684-3210
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Fax | 601-684-3319
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Authorized Official
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Title or Position | OFFICE ADMINISTRATOR
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Name | MRS. LINDA YOUNG BROCK
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Credential |
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Telephone | 601-684-3210
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | 7285
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License Number State | MS
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