Provider Demographics
NPI:1750308250
Name:SOUTH MISSISSIPPI URGENT CARE
Entity type:Organization
Organization Name:SOUTH MISSISSIPPI URGENT CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:ALI
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:228-539-2399
Mailing Address - Street 1:3661 SANGANI BLVD.
Mailing Address - Street 2:SUITE E
Mailing Address - City:DLBERVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39540
Mailing Address - Country:US
Mailing Address - Phone:228-354-0022
Mailing Address - Fax:228-354-0088
Practice Address - Street 1:3661 SANGANI BLVD
Practice Address - Street 2:SUITE E
Practice Address - City:DLBERVILLE
Practice Address - State:MS
Practice Address - Zip Code:39540
Practice Address - Country:US
Practice Address - Phone:228-354-0022
Practice Address - Fax:228-354-0088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2013-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01938518Medicaid
MS=========OtherTRICARE
MSC03536Medicare PIN