Basic Information
Provider Information | |||||||||
NPI: | 1861739161 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | KDMC PHYSICIAN CLINICS LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 427 HIGHWAY 51 N | ||||||||
Address2: |   | ||||||||
City: | BROOKHAVEN | ||||||||
State: | MS | ||||||||
PostalCode: | 396012350 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6018336011 | ||||||||
FaxNumber: | 6018232206 | ||||||||
Practice Location | |||||||||
Address1: | 950 BROOKWAY BLVD | ||||||||
Address2: |   | ||||||||
City: | BROOKHAVEN | ||||||||
State: | MS | ||||||||
PostalCode: | 396012644 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6018235103 | ||||||||
FaxNumber: | 6018233514 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/08/2013 | ||||||||
LastUpdateDate: | 01/08/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PIRTLE | ||||||||
AuthorizedOfficialFirstName: | RANDY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 6018336011 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | KINGS DAUGHTERS MEDICAL CENTER | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.