Provider Demographics
NPI:1417949058
Name:HIGHWAY 15 MEDICAL CLINIC PA
Entity Type:Organization
Organization Name:HIGHWAY 15 MEDICAL CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:THORNTON
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:662-534-4706
Mailing Address - Street 1:124 HIGHWAY 15 S
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:MS
Mailing Address - Zip Code:38652-5225
Mailing Address - Country:US
Mailing Address - Phone:662-534-4706
Mailing Address - Fax:662-534-8065
Practice Address - Street 1:124 HIGHWAY 15 S
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:MS
Practice Address - Zip Code:38652-5225
Practice Address - Country:US
Practice Address - Phone:662-534-4706
Practice Address - Fax:662-534-8065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09016044Medicaid
MSC02856Medicare ID - Type UnspecifiedCAHABA
MS09016044Medicaid