=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811592454
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTH MISSISSIPPI VASCULAR CARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/02/2020
-----------------------------------------------------
Last Update Date | 02/03/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 425 HOSPITAL DR STE 4A
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39705-1901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-368-1169
-----------------------------------------------------
Fax | 662-570-1492
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3001 PALM HARBOR BLVD STE A
-----------------------------------------------------
City | PALM HARBOR
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34683-1930
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-474-0090
-----------------------------------------------------
Fax | 727-474-0055
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JOHN KING
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 662-368-1169
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RI0011X
-----------------------------------------------------
Taxonomy Name | Interventional Cardiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------