Provider Demographics
NPI:1194026260
Name:STATCARE PLLC
Entity Type:Organization
Organization Name:STATCARE PLLC
Other - Org Name:STATCARE PLUS, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-250-1122
Mailing Address - Street 1:1015 DELAWARE AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39648-3827
Mailing Address - Country:US
Mailing Address - Phone:601-249-4777
Mailing Address - Fax:601-249-4776
Practice Address - Street 1:1015 DELAWARE AVE
Practice Address - Street 2:SUITE C
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648-3827
Practice Address - Country:US
Practice Address - Phone:601-249-4777
Practice Address - Fax:601-249-4776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-05
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS302G707746Medicare PIN