Provider Demographics
NPI:1053491605
Name:DERMATOLOGY CENTER OF NORTH MS PA
Entity Type:Organization
Organization Name:DERMATOLOGY CENTER OF NORTH MS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:D
Authorized Official - Last Name:BURK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-844-6272
Mailing Address - Street 1:516 PEGRAM DR
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-6347
Mailing Address - Country:US
Mailing Address - Phone:662-844-6272
Mailing Address - Fax:662-844-1603
Practice Address - Street 1:516 PEGRAM DR
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-6347
Practice Address - Country:US
Practice Address - Phone:662-844-6272
Practice Address - Fax:662-844-1603
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS7919207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS9015434Medicaid
MS9015434Medicaid