Provider Demographics
NPI:1932144243
Name:PSP MEDICAL CLINIC LLC
Entity Type:Organization
Organization Name:PSP MEDICAL CLINIC LLC
Other - Org Name:MADISON CANTON MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NEELAM
Authorized Official - Middle Name:
Authorized Official - Last Name:GOEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-859-9888
Mailing Address - Street 1:P.O. BOX 607
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MS
Mailing Address - Zip Code:39157
Mailing Address - Country:US
Mailing Address - Phone:601-859-9888
Mailing Address - Fax:601-859-9966
Practice Address - Street 1:1171 HART ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MS
Practice Address - Zip Code:39046-4805
Practice Address - Country:US
Practice Address - Phone:601-859-9888
Practice Address - Fax:601-859-9966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS15405261QR1300X, 261QR1300X
261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS25D1052898OtherCLIA
MS00118231Medicaid
MS02679823Medicaid
MSC03491Medicare ID - Type UnspecifiedGROUP
MSG51199Medicare UPIN
MS110001977Medicare ID - Type UnspecifiedINDIVIDUAL