Provider Demographics
NPI:1255424016
Name:VIBHA VIG MD PA
Entity type:Organization
Organization Name:VIBHA VIG MD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VIBHA
Authorized Official - Middle Name:
Authorized Official - Last Name:VIG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-855-5287
Mailing Address - Street 1:PO BOX 626
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MS
Mailing Address - Zip Code:39046-0626
Mailing Address - Country:US
Mailing Address - Phone:601-267-0544
Mailing Address - Fax:601-267-5092
Practice Address - Street 1:303 ELLIS ST.
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:MS
Practice Address - Zip Code:39051-4014
Practice Address - Country:US
Practice Address - Phone:601-267-0544
Practice Address - Fax:601-267-5092
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13655261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015926Medicaid