NPIMap

Organization Active NPI

Dermatology Center of North Ms PA

  • Dermatology Physician
  • Tupelo, MS
National Provider Identifier
1053491605
Registry record updated Mar 26, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
Dermatology PhysicianTaxonomy code 207N00000X
License
7919 Issued in MS
Legal business name
DERMATOLOGY CENTER OF NORTH MS PA
Practice address
516 Pegram Dr
Tupelo, MS 38801-6347
Phone
(662) 844-6272
Fax
(662) 844-1603
NPI assigned
Oct 17, 2006
Last updated
Mar 26, 2015By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 26, 2015

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. John D Burk, MDNPI 1518991033
Title
President
Phone
(662) 844-6272

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Dermatology Physician 207N00000X 7919 MS Primary

Addresses

Primary practice location

516 Pegram Dr
Tupelo, MS 38801-6347

Mailing address

516 Pegram Dr
Tupelo, MS 38801-6347
Phone (662) 844-6272

Other identifiers 1

IdentifierTypeStateIssuer
9015434MedicaidMS

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MS

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20090513000267 MS Part B Supplier - Clinic/Group Practice 7416006986 Receives reassigned benefits from 8 practitioners
Practice locations: Tupelo, MS

National Provider Directory

National Provider Directory

Locations

340 Court St
Tupelo, MS 38804
Phone (662) 844-6272

516 Pegram Dr
Tupelo, MS 38801
Phone (662) 844-6272

Practitioners & affiliated clinicians

Practitioners 8

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1161043200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1427328000000",
    "number": "1053491605",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "516 PEGRAM DR",
            "city": "TUPELO",
            "state": "MS",
            "postal_code": "388016347",
            "telephone_number": "662-844-6272",
            "fax_number": "662-844-1603"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "516 PEGRAM DR",
            "city": "TUPELO",
            "state": "MS",
            "postal_code": "388016347",
            "telephone_number": "662-844-6272",
            "fax_number": "662-844-1603"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DERMATOLOGY CENTER OF NORTH MS PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-10-17",
        "last_updated": "2015-03-26",
        "status": "A",
        "authorized_official_last_name": "BURK",
        "authorized_official_first_name": "JOHN",
        "authorized_official_middle_name": "D",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "662-844-6272",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "",
            "desc": "Dermatology",
            "state": "MS",
            "license": "7919",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "9015434",
            "state": "MS"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Tupelo, MS

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 26, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.