Provider Demographics
NPI:1821185786
Name:THE SURGICAL CLINIC ASSOCIATES, P.A.
Entity Type:Organization
Organization Name:THE SURGICAL CLINIC ASSOCIATES, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:HICKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:601-948-1411
Mailing Address - Street 1:501 MARSHALL ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-1651
Mailing Address - Country:US
Mailing Address - Phone:601-948-1411
Mailing Address - Fax:601-948-0090
Practice Address - Street 1:501 MARSHALL ST
Practice Address - Street 2:SUITE 500
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-1651
Practice Address - Country:US
Practice Address - Phone:601-948-1411
Practice Address - Fax:601-948-0090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2009-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09012031Medicaid
MS09012031Medicaid