Provider Demographics
NPI:1023419801
Name:VICKSBURG MEDICAL TEAMS MHT LLC
Entity type:Organization
Organization Name:VICKSBURG MEDICAL TEAMS MHT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SAM
Authorized Official - Middle Name:
Authorized Official - Last Name:PIERCE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-262-1000
Mailing Address - Street 1:1515 HERITAGE DRIVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:MCKINNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75069-3379
Mailing Address - Country:US
Mailing Address - Phone:817-470-7377
Mailing Address - Fax:877-343-3192
Practice Address - Street 1:2080 S FRONTAGE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-5328
Practice Address - Country:US
Practice Address - Phone:601-529-5466
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-11
Last Update Date:2015-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty