Basic Information
| Provider Information | |||||||||
| NPI: | 1003191867 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GLUCKSTADT SPECIAL CARE CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1716 HIGHWAY 51 STE M | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391105020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017075621 | ||||||||
| FaxNumber: | 6017079052 | ||||||||
| Practice Location | |||||||||
| Address1: | 1716 HIGHWAY 51 STE M | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391105020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017075621 | ||||||||
| FaxNumber: | 6017079052 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2011 | ||||||||
| LastUpdateDate: | 10/12/2011 | ||||||||
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| AuthorizedOfficialLastName: | CONNER | ||||||||
| AuthorizedOfficialFirstName: | KAREN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF CLIENT SOLUTIONS | ||||||||
| AuthorizedOfficialTelephone: | 3182557591 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CPC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.