Provider Demographics
NPI:1891171351
Name:PRIME URGENT MEDICAL CLINIC
Entity Type:Organization
Organization Name:PRIME URGENT MEDICAL CLINIC
Other - Org Name:PRIME URGENT MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:CLARK
Authorized Official - Middle Name:
Authorized Official - Last Name:LEVI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:228-447-3823
Mailing Address - Street 1:1019 GOVERNMENT ST
Mailing Address - Street 2:SUITE F
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-3860
Mailing Address - Country:US
Mailing Address - Phone:288-447-3823
Mailing Address - Fax:228-447-3812
Practice Address - Street 1:176 GOODMAN RD W
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-9405
Practice Address - Country:US
Practice Address - Phone:662-510-6981
Practice Address - Fax:662-510-6987
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-07
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS144403336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2153376OtherPK