Provider Demographics
NPI:1598015968
Name:URBAN MEDICAL CLINIC, INC.
Entity Type:Organization
Organization Name:URBAN MEDICAL CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KERMIT
Authorized Official - Middle Name:LAMAR
Authorized Official - Last Name:WALTERS
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:318-325-7998
Mailing Address - Street 1:1910 JACKSON ST.
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71202-2532
Mailing Address - Country:US
Mailing Address - Phone:318-325-7998
Mailing Address - Fax:318-398-0888
Practice Address - Street 1:1910 JACKSON ST.
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71202-2532
Practice Address - Country:US
Practice Address - Phone:318-325-7998
Practice Address - Fax:318-398-0888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-13
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1797715Medicaid