NPIMap

Organization Active NPI

Statcare PLLC

  • Clinic/Center
  • McComb, MS
National Provider Identifier
1174579338
Registry record updated Oct 23, 2007
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinic/CenterTaxonomy code 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
Last updated
Oct 23, 2007By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 23, 2007

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

Authorized official

Name
Debra B Kennedy
Title
Office Manager
Phone
(601) 250-1122

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Clinic/Center 261Q00000X Primary

Addresses

Primary practice location

1017 Delaware Ave
McComb, MS 39648-3827

Mailing address

PO Box 1909
McComb, MS 39649-1909
Phone (601) 250-1122

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MS2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
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

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
25D1013463Statcare PLLC1017 Delaware Avenue, McComb, MS 39648ComplianceApr 5, 2028

National Provider Directory

National Provider Directory
Tax ID family
Statcare PLLC2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Locations

1015 Delaware Ave
Ste C
McComb, MS 39648
Phone (601) 249-4777

Practitioners & affiliated clinicians

Practitioners 17

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.

View all 17

NPI Registry JSON

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

{
    "created_epoch": "1148601600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1193097600000",
    "number": "1174579338",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1909",
            "city": "MCCOMB",
            "state": "MS",
            "postal_code": "396491909",
            "telephone_number": "601-250-1122",
            "fax_number": "601-250-0290"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1017 DELAWARE AVE",
            "city": "MCCOMB",
            "state": "MS",
            "postal_code": "396483827",
            "telephone_number": "601-250-1122",
            "fax_number": "601-250-0290"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "STATCARE PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-26",
        "last_updated": "2007-10-23",
        "status": "A",
        "authorized_official_last_name": "KENNEDY",
        "authorized_official_first_name": "DEBRA",
        "authorized_official_middle_name": "B",
        "authorized_official_title_or_position": "OFFICE MANAGER",
        "authorized_official_telephone_number": "601-250-1122"
    },
    "taxonomies": [
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in McComb, MS

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 23, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.