Provider Demographics
NPI:1073566550
Name:KELLY S SEGARS MD PC
Entity Type:Organization
Organization Name:KELLY S SEGARS MD PC
Other - Org Name:THE SEGARS CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MONA
Authorized Official - Middle Name:A
Authorized Official - Last Name:MCWILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-423-1000
Mailing Address - Street 1:1507 W QUITMAN ST
Mailing Address - Street 2:
Mailing Address - City:IUKA
Mailing Address - State:MS
Mailing Address - Zip Code:38852-1132
Mailing Address - Country:US
Mailing Address - Phone:662-423-1000
Mailing Address - Fax:662-423-1316
Practice Address - Street 1:1507 W QUITMAN ST
Practice Address - Street 2:
Practice Address - City:IUKA
Practice Address - State:MS
Practice Address - Zip Code:38852-1132
Practice Address - Country:US
Practice Address - Phone:662-423-1000
Practice Address - Fax:662-423-1316
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2012-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS12314174400000X
MS10016174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00017574Medicaid
MS1609871607OtherNPI
MS487623030OtherBCBS
MS587922966OtherBCBS
MS011800024OtherRAILROAD MEDICARE
MS1649429481OtherNPI
MS1750386488OtherNPI
MS5121500528OtherPTAN
MS05989006Medicaid
MS5121500341OtherPTAN
MSP00123795OtherRAILROAD MEDICARE
MS587286250OtherBCBS
MS00013060Medicaid
MS04426008Medicaid
MS1750387890OtherNPI
MS500001207OtherPTAN
MS03171239Medicaid
MS080117421OtherRAILROAD MEDICARE
MS418807663OtherBCBS
MS428559600OtherBLUE CROSS BLUE SHIELD
MS00835093Medicaid
MS1124298849OtherNPI
MS420866905OtherBCBS
MS5121500528OtherPTAN
MS080117421OtherRAILROAD MEDICARE
MS1750387890OtherNPI
MS00835093Medicaid
MS302I500631Medicare PIN