Basic Information
| Provider Information | |||||||||
| NPI: | 1700316536 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PATEL | ||||||||
| FirstName: | BHAVIK | ||||||||
| MiddleName: | S | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 490 | ||||||||
| Address2: | |||||||||
| City: | MCCOMB | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396490490 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012492701 | ||||||||
| FaxNumber: | 6012492195 | ||||||||
| Practice Location | |||||||||
| Address1: | 1506 ASTON AVE | ||||||||
| Address2: | |||||||||
| City: | MCCOMB | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396482735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012494282 | ||||||||
| FaxNumber: | 6012494852 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2017 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | AP09299 | LA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LA2100X | 902013 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | 02121003 | 05 | MS | MEDICAID |