Provider Demographics
NPI:1114196664
Name:VICKSBURG EMERGENCY PHYSICIANS LLP
Entity Type:Organization
Organization Name:VICKSBURG EMERGENCY PHYSICIANS LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LLP, MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DERIK
Authorized Official - Middle Name:K
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:866-916-5259
Mailing Address - Street 1:PO BOX 60259
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33906-6259
Mailing Address - Country:US
Mailing Address - Phone:866-916-5259
Mailing Address - Fax:231-922-4030
Practice Address - Street 1:2100 HIGHWAY 61 N
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39183-8211
Practice Address - Country:US
Practice Address - Phone:601-833-5000
Practice Address - Fax:601-833-5197
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-28
Last Update Date:2008-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07183331Medicaid
LA1179779Medicaid
MS512G700178Medicare PIN