Provider Demographics
NPI:1912165523
Name:MEDICAL CLINIC OF MISSISSIPPI
Entity Type:Organization
Organization Name:MEDICAL CLINIC OF MISSISSIPPI
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DINESH
Authorized Official - Middle Name:KUMAN
Authorized Official - Last Name:GOEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD,
Authorized Official - Phone:601-957-5150
Mailing Address - Street 1:6050 I-55 NORTH FRONTAGE RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211
Mailing Address - Country:US
Mailing Address - Phone:601-957-5150
Mailing Address - Fax:601-957-5161
Practice Address - Street 1:6050 I-55 NORTH FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211
Practice Address - Country:US
Practice Address - Phone:601-957-5150
Practice Address - Fax:601-957-5161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-30
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS07606207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09014739Medicaid
MSB66109Medicare UPIN
MS09014739Medicaid