Statcare PLLC
Organization Active NPI Clinic/Center · McComb, MS
NPI 1174579338 · NPPES record last updated Oct 23, 2007
Key facts
- NPI
- 1174579338
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Clinic/Center 261Q00000X
- Legal business name
- STATCARE PLLC
- Practice address
- 1017 Delaware Ave
McComb, MS 39648-3827 - Phone
- (601) 250-1122
- Fax
- (601) 250-0290
- NPI assigned
- May 26, 2006
- Organization subpart
- No
Authorized official
- Name
- Debra B Kennedy
- Title
- Office Manager
- Phone
- (601) 250-1122
Other NPIs on the same Medicare enrollment 1
Corporate family (same tax ID) 1
Practitioners 17
-
Jackie Eugene Brister, F.N.P.
-
Brett Ferman, MD
-
John Harvey, FNP-C
-
Scott Farr Smith, M.D.
-
Darryl Temple, FNP
-
Brett Bienville Tisdale, M.D.
-
Jodi Waller, FNP-C
-
John Andrew Watson, D.O.
-
Melanie Dawne Robertson, FNP-C
-
George Arthur Applewhite, M.D.
-
Llewellyn Coon, CNFP
-
Lennis Joseph Derouen, M.D.
-
William N Dixon, M.D.
-
Clifton Dale Williams, M.D.
-
John F Kliesch, MD
-
Patrick Leroy McGauly, M.D.
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 25D1013463 | Statcare PLLC | Compliance | Apr 5, 2028 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in MS
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20040720000687 | MS | Part B Supplier - Clinic/Group Practice | 5799764965 |
Receives reassigned benefits from 10 practitioners 1 other NPI on this enrollment Practice locations: McComb, MS; Summit, MS |
| O20100930078336 | MS | DME Supplier - Physician - Emergency Medicine | 5799764965 | Practice locations: McComb, MS |
National Provider Directory
- Tax ID family
- Statcare PLLC
Locations
1017 Delaware Ave
McComb, MS 39648
Phone (601) 250-1122
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinic/Center | 261Q00000X | Yes |
Addresses
Primary practice location
1017 Delaware Ave
McComb, MS 39648-3827
Mailing address
PO Box 1909
McComb, MS 39649-1909
Phone (601) 250-1122
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| CN2774 | Other | MS | MEDICARE RAILROAD |
Other providers in McComb, MS
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Oct 23, 2007. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.