Provider Demographics
NPI:1073600409
Name:MCCOMB UROLOGY CLINIC, P.A.
Entity Type:Organization
Organization Name:MCCOMB UROLOGY CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:BENJAMIN
Authorized Official - Last Name:SIMO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-684-1261
Mailing Address - Street 1:300 RAWLS DR STE 1000
Mailing Address - Street 2:
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39648-2861
Mailing Address - Country:US
Mailing Address - Phone:601-684-1261
Mailing Address - Fax:601-684-3649
Practice Address - Street 1:300 RAWLS DR STE 1000
Practice Address - Street 2:
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648-2861
Practice Address - Country:US
Practice Address - Phone:601-684-1261
Practice Address - Fax:601-684-3649
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS7944174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00016344Medicaid
MS00016344Medicaid