Provider Demographics
NPI:1740448653
Name:MCCOMB SKIN CLINIC PA
Entity type:Organization
Organization Name:MCCOMB SKIN CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:YOUNG
Authorized Official - Last Name:BROCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-684-3210
Mailing Address - Street 1:136 MARION AVE
Mailing Address - Street 2:
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39648-3620
Mailing Address - Country:US
Mailing Address - Phone:601-684-3210
Mailing Address - Fax:601-684-3319
Practice Address - Street 1:136 MARION AVE
Practice Address - Street 2:
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648-3620
Practice Address - Country:US
Practice Address - Phone:601-684-3210
Practice Address - Fax:601-684-3319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-28
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS7285207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09014899Medicaid
MS09014899Medicaid
MS=========OtherSTATE OF MS CLAIMS ADMINISTRATOR
MS09014899Medicaid
MS512G700186Medicare PIN