Basic Information
| Provider Information | |||||||||
| NPI: | 1255424016 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VIBHA VIG MD PA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SUNSHINE MEDICAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 626 | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 390460626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012670544 | ||||||||
| FaxNumber: | 6012675092 | ||||||||
| Practice Location | |||||||||
| Address1: | 303 ELLIS ST. | ||||||||
| Address2: | |||||||||
| City: | CARTHAGE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 390514014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012670544 | ||||||||
| FaxNumber: | 6012675092 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 07/21/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | VIG | ||||||||
| AuthorizedOfficialFirstName: | VIBHA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6018555287 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | 13655 | MS | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 09015926 | 05 | MS | MEDICAID |