Provider Demographics
NPI:1114694536
Name:MISSISSIPPI MEDICAL CLINIC
Entity Type:Organization
Organization Name:MISSISSIPPI MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NP MANAGING PARTNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATTY
Authorized Official - Middle Name:
Authorized Official - Last Name:BULLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:601-452-7080
Mailing Address - Street 1:403 PINE ST
Mailing Address - Street 2:
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39168-5659
Mailing Address - Country:US
Mailing Address - Phone:601-452-7080
Mailing Address - Fax:601-452-7083
Practice Address - Street 1:403 PINE ST
Practice Address - Street 2:
Practice Address - City:TAYLORSVILLE
Practice Address - State:MS
Practice Address - Zip Code:39168-5659
Practice Address - Country:US
Practice Address - Phone:601-452-7080
Practice Address - Fax:601-452-7083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-24
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty