Provider Demographics
NPI:1093499907
Name:MISSISSIPPI MEDICAL CLINIC OF MENDEHALL
Entity Type:Organization
Organization Name:MISSISSIPPI MEDICAL CLINIC OF MENDEHALL
Other - Org Name:MISSISSIPPI MEDICAL CLINIC MENDENHALL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHANTE
Authorized Official - Middle Name:N
Authorized Official - Last Name:FERGUSON
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:601-675-1200
Mailing Address - Street 1:PO BOX 335
Mailing Address - Street 2:
Mailing Address - City:MAGEE
Mailing Address - State:MS
Mailing Address - Zip Code:39111-0335
Mailing Address - Country:US
Mailing Address - Phone:601-675-1200
Mailing Address - Fax:601-675-1209
Practice Address - Street 1:2170 SIMPSON HIGHWAY 49
Practice Address - Street 2:
Practice Address - City:MENDENHALL
Practice Address - State:MS
Practice Address - Zip Code:39114-5418
Practice Address - Country:US
Practice Address - Phone:601-675-1200
Practice Address - Fax:601-375-1209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-12
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty