Basic Information
| Provider Information | |||||||||
| NPI: | 1346592045 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GOLDEN TRIANGLE URGENT CARE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 BURTON HILLS BLVD | ||||||||
| Address2: | SUITE 175 | ||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372156403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6159882009 | ||||||||
| FaxNumber: | 6152509773 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 RUSSELL ST STE 3 | ||||||||
| Address2: | |||||||||
| City: | STARKVILLE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 397595411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6623242244 | ||||||||
| FaxNumber: | 6623242295 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2012 | ||||||||
| LastUpdateDate: | 12/25/2020 | ||||||||
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| AuthorizedOfficialLastName: | BLANK | ||||||||
| AuthorizedOfficialFirstName: | RUDY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6159882005 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 261QR1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Rural Health | 261QU0200X | N | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care | 363LF0000X | N | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 04351854 | 05 | MS | MEDICAID |