Provider Demographics
NPI:1902837313
Name:MISSISSIPPI UROLOGY CLINIC, PLLC
Entity Type:Organization
Organization Name:MISSISSIPPI UROLOGY CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF ADMINISTRATIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:KEMPF
Authorized Official - Last Name:POOLE
Authorized Official - Suffix:
Authorized Official - Credentials:RN, FACHE
Authorized Official - Phone:601-985-3169
Mailing Address - Street 1:501 MARHSALL ST
Mailing Address - Street 2:SUITE 301
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202
Mailing Address - Country:US
Mailing Address - Phone:601-353-9900
Mailing Address - Fax:601-985-3199
Practice Address - Street 1:501 MARHSALL ST
Practice Address - Street 2:SUITE 301
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202
Practice Address - Country:US
Practice Address - Phone:601-353-9900
Practice Address - Fax:601-985-3199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSCD5655OtherMEDICARE RR
MSCD5655OtherMEDICARE RR
MSCD5655OtherMEDICARE RR