Provider Demographics
NPI:1164727285
Name:BROAD AVENUE URGENT CARE
Entity Type:Organization
Organization Name:BROAD AVENUE URGENT CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ALI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:228-314-1340
Mailing Address - Street 1:PO BOX 1248
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39566-1248
Mailing Address - Country:US
Mailing Address - Phone:228-314-1340
Mailing Address - Fax:228-314-1342
Practice Address - Street 1:1104 BROAD AVE
Practice Address - Street 2:SUITE B
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2414
Practice Address - Country:US
Practice Address - Phone:228-314-1340
Practice Address - Fax:228-314-1342
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-20
Last Update Date:2011-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care