Provider Demographics
NPI:1790706463
Name:PACIFIC PHYSICIAN SERVICES, LLC
Entity Type:Organization
Organization Name:PACIFIC PHYSICIAN SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:T
Authorized Official - Last Name:BREWER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-892-9813
Mailing Address - Street 1:39 FRANKLIN RD
Mailing Address - Street 2:SUITE 220
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-1588
Mailing Address - Country:US
Mailing Address - Phone:601-450-2401
Mailing Address - Fax:
Practice Address - Street 1:39 FRANKLIN RD
Practice Address - Street 2:SUITE 220
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-1588
Practice Address - Country:US
Practice Address - Phone:601-450-2401
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2007-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03688866Medicaid
MS03688866Medicaid