Provider Demographics
NPI:1508231994
Name:VAN WURM MD,PLLC
Entity Type:Organization
Organization Name:VAN WURM MD,PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:VAN
Authorized Official - Last Name:WURM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:228-818-0585
Mailing Address - Street 1:3631 BIENVILLE BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-5702
Mailing Address - Country:US
Mailing Address - Phone:228-818-0585
Mailing Address - Fax:228-818-0588
Practice Address - Street 1:3631 BIENVILLE BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-5702
Practice Address - Country:US
Practice Address - Phone:228-818-0585
Practice Address - Fax:228-818-0588
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-10
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208000000X
MS20580261QM2500X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03673557Medicaid