Provider Demographics
NPI:1598449167
Name:MEDICAL CLINIC LLC
Entity Type:Organization
Organization Name:MEDICAL CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:PACE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:864-915-1949
Mailing Address - Street 1:PO BOX 518
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:MS
Mailing Address - Zip Code:39654-0518
Mailing Address - Country:US
Mailing Address - Phone:864-915-1949
Mailing Address - Fax:
Practice Address - Street 1:713 WATTS ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:MS
Practice Address - Zip Code:39654-9313
Practice Address - Country:US
Practice Address - Phone:601-587-7795
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-13
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1780849109OtherNURSE PRACTITIONER
MS1780849109Medicaid