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General NPI Number Information
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NPI Number | 1790711158
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Entity Type | Organization
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Legal Business Name | VICKSBURG CLINIC LLC
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Dates
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Enumeration Date | 06/25/2006
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Last Update Date | 11/20/2024
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Provider Practice Location Address
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Address Line | 2100 HIGHWAY 61 N
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City | VICKSBURG
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State | MS
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Zip | 39183-8211
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Country | US
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Telephone | 601-883-5000
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 689022
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City | FRANKLIN
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State | TN
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Zip | 37068-9022
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | DIRECTOR PROVIDER ENROLLMENT
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Name | KRISTINA MUSIC
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Credential |
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Telephone | 615-465-7000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0001X
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Taxonomy Name | Radiation Oncology Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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