Basic Information
Provider Information | |||||||||
NPI: | 1982634051 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NATCHEZ AFTER HOURS CLINIC, P.L.L.C. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 18261 | ||||||||
Address2: |   | ||||||||
City: | NATCHEZ | ||||||||
State: | MS | ||||||||
PostalCode: | 391228261 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6014421900 | ||||||||
FaxNumber: | 6014421908 | ||||||||
Practice Location | |||||||||
Address1: | 46 SEARGENT PRENTESS DRIVE | ||||||||
Address2: | SUITE 101 | ||||||||
City: | NATCHEZ | ||||||||
State: | MS | ||||||||
PostalCode: | 391204725 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6014421900 | ||||||||
FaxNumber: | 6014421908 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/04/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MIRE | ||||||||
AuthorizedOfficialFirstName: | BLANE | ||||||||
AuthorizedOfficialMiddleName: | ANDREW | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 6014467342 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 15913 | MS | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |   |
No ID Information.