Active NPI
Mission Primary Care Clinic PLLC
- Family Medicine Physician
- Vicksburg, MS
National Provider Identifier
1487852018
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Family Medicine Physician
- Legal business name
- MISSION PRIMARY CARE CLINIC PLLC
- Practice address
- 1901 Mission 66
Vicksburg, MS 39180-3711 - Phone
- (601) 636-0097
- Fax
- (601) 629-9969
- NPI assigned
- Jul 5, 2007
- Organization subpart
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Authorized official
- Name
- Bill Fulcher
- Title
- Adm
- Phone
- (601) 636-0097
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | Primary | ||
| Family Nurse Practitioner | 363LF0000X | R829001 | MS |
Addresses
Primary practice location
1901 Mission 66
Vicksburg, MS 39180-3711
Mailing address
1901 Mission 66
Vicksburg, MS 39180-3711
Phone (601) 636-0097
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 04935090 | Medicaid | MS |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in MS
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20040927000415 | MS | Part B Supplier - Clinic/Group Practice | 5890764914 |
Receives reassigned benefits from 6 practitioners Practice locations: Vicksburg, MS |
Laboratory certificates & supplier records
Derived by NPIMapThese CMS records do not include an NPI. They are shown because their name and street address match this provider’s.
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 25D0901653 | Mission Primary Care Clinic | Compliance | Jul 5, 2028 |
National Provider Directory
National Provider DirectoryPractitioners & affiliated clinicians
Practitioners 12
Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1183593600000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1653436800000",
"number": "1487852018",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1901 MISSION 66",
"city": "VICKSBURG",
"state": "MS",
"postal_code": "391803711",
"telephone_number": "601-636-0097",
"fax_number": "601-629-9969"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1901 MISSION 66",
"city": "VICKSBURG",
"state": "MS",
"postal_code": "391803711",
"telephone_number": "601-636-0097",
"fax_number": "601-629-9969"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "MISSION PRIMARY CARE CLINIC PLLC",
"organizational_subpart": "NO",
"enumeration_date": "2007-07-05",
"last_updated": "2022-05-25",
"certification_date": "2022-05-25",
"status": "A",
"authorized_official_last_name": "FULCHER",
"authorized_official_first_name": "BILL",
"authorized_official_title_or_position": "ADM",
"authorized_official_telephone_number": "601-636-0097"
},
"taxonomies": [
{
"code": "207Q00000X",
"taxonomy_group": "193400000X SINGLE SPECIALTY GROUP",
"desc": "Family Medicine",
"state": null,
"license": null,
"primary": true
},
{
"code": "363LF0000X",
"taxonomy_group": "193400000X SINGLE SPECIALTY GROUP",
"desc": "Nurse Practitioner, Family",
"state": "MS",
"license": "R829001",
"primary": false
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "04935090",
"state": "MS"
}
],
"endpoints": [],
"other_names": []
}Other providers in Vicksburg, MS
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 25, 2022; 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.