Provider Demographics
NPI:1740293257
Name:WIGGINS PRIMARY CARE
Entity type:Organization
Organization Name:WIGGINS PRIMARY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:FENDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-947-8181
Mailing Address - Street 1:PO BOX 1007
Mailing Address - Street 2:
Mailing Address - City:LUCEDALE
Mailing Address - State:MS
Mailing Address - Zip Code:39452-1007
Mailing Address - Country:US
Mailing Address - Phone:601-528-9119
Mailing Address - Fax:601-528-9193
Practice Address - Street 1:975 HALL ST
Practice Address - Street 2:
Practice Address - City:WIGGINS
Practice Address - State:MS
Practice Address - Zip Code:39577-2107
Practice Address - Country:US
Practice Address - Phone:601-528-9119
Practice Address - Fax:601-528-9193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS207Q00000X
261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSC03308OtherMEDICARE CAHABA
MS00488801Medicaid
MSC03308OtherMEDICARE CAHABA
MS00488801Medicaid