Provider Demographics
NPI:1952476921
Name:PLANTERSVILLE CLINIC, INC
Entity Type:Organization
Organization Name:PLANTERSVILLE CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:W
Authorized Official - Last Name:HILL
Authorized Official - Suffix:
Authorized Official - Credentials:CFNP
Authorized Official - Phone:662-842-4877
Mailing Address - Street 1:PO BOX 219
Mailing Address - Street 2:
Mailing Address - City:PLANTERSVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38862-0219
Mailing Address - Country:US
Mailing Address - Phone:662-842-4877
Mailing Address - Fax:
Practice Address - Street 1:2464 MAIN ST.
Practice Address - Street 2:
Practice Address - City:PLANTERSVILLE
Practice Address - State:MS
Practice Address - Zip Code:38862
Practice Address - Country:US
Practice Address - Phone:662-842-4877
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR713511363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02853062Medicaid
MS02853062Medicaid