Provider Demographics
NPI:1629536925
Name:D'IBERVILLE MEDICAL CLINIC LLC
Entity Type:Organization
Organization Name:D'IBERVILLE MEDICAL CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:R
Authorized Official - Last Name:ADKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:228-861-6049
Mailing Address - Street 1:PO BOX 1277
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39533-1277
Mailing Address - Country:US
Mailing Address - Phone:228-207-4190
Mailing Address - Fax:228-207-4156
Practice Address - Street 1:11516 LAMEY BRIDGE RD
Practice Address - Street 2:STE 1
Practice Address - City:DIBERVILLE
Practice Address - State:MS
Practice Address - Zip Code:39540-2725
Practice Address - Country:US
Practice Address - Phone:228-207-4190
Practice Address - Fax:228-207-4190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-05
Last Update Date:2019-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty