Provider Demographics
NPI:1497188460
Name:VICKSBURG HMA PHYSICIAN MGMT
Entity Type:Organization
Organization Name:VICKSBURG HMA PHYSICIAN MGMT
Other - Org Name:MEDICAL ASSOCIATES OF VICKSBURG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:H
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-262-1000
Mailing Address - Street 1:2080 S FRONTAGE RD
Mailing Address - Street 2:STE 100
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180-5328
Mailing Address - Country:US
Mailing Address - Phone:601-262-1000
Mailing Address - Fax:601-262-1211
Practice Address - Street 1:2080 S FRONTAGE RD
Practice Address - Street 2:STE 100
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-5328
Practice Address - Country:US
Practice Address - Phone:601-262-1000
Practice Address - Fax:601-262-1211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-14
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR871321363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty