NPIMap

Organization Active NPI

Vicksburg Clinic LLC

  • Infectious Disease Physician
  • Vicksburg, MS
National Provider Identifier
1659307791
Registry record updated Nov 25, 2008
On this page

Key facts

NPPES NPI Registry
Primary specialty
Infectious Disease PhysicianTaxonomy code 207RI0200X
Legal business name
VICKSBURG CLINIC LLC
Practice address
1115 N Frontage Rd
Vicksburg, MS 39180-5102
Phone
(601) 634-8790
NPI assigned
Jun 23, 2006
Last updated
Nov 25, 2008By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 25, 2008

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

Authorized official

Name
Debbie T Brewer
Title
Director of Provider Enrollment
Phone
(877) 892-9813

Specialties & licenses 13

Specialty (taxonomy)CodeLicenseStatePrimary
Nurse Practitioner 363L00000X
Allergy Physician 207KA0200X
Family Medicine Physician 207Q00000X
Internal Medicine Physician 207R00000X
Cardiovascular Disease Physician 207RC0000X
Infectious Disease Physician 207RI0200X Primary
Pulmonary Disease Physician 207RP1001X
Obstetrics Physician 207VX0000X
Orthopaedic Surgery Physician 207X00000X
Pediatrics Physician 208000000X
Neurology Physician 2084N0400X
Surgery Physician 208600000X
Urology Physician 208800000X

Addresses

Primary practice location

1115 N Frontage Rd
Vicksburg, MS 39180-5102

Mailing address

1115 N Frontage Rd
Vicksburg, MS 39180-5102
Phone (601) 634-8790

Other identifiers 6

IdentifierTypeStateIssuer
09015546MedicaidMS
09015547MedicaidMS
00720204MedicaidMS
1111716MedicaidLA
09015545MedicaidMS
09015549MedicaidMS

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040116000738 MS Part B Supplier - Clinic/Group Practice 5890696330 Receives reassigned benefits from 42 practitioners
3 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Brandon, MS; Vicksburg, MS; Rolling Fork, MS; Port Gibson, MS; Natchez, MS; Jackson, MS; Greenville, MS; Fayette, MS…

Other NPIs on the same Medicare enrollment 3

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

National Provider Directory

National Provider Directory

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

Locations

1115 N Frontage Rd
Vicksburg, MS 39180
Phone (601) 634-8790

Practitioners & affiliated clinicians

Practitioners 72

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 72

NPI Registry JSON

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

{
    "created_epoch": "1151020800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1227571200000",
    "number": "1659307791",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1115 N FRONTAGE RD",
            "city": "VICKSBURG",
            "state": "MS",
            "postal_code": "391805102",
            "telephone_number": "601-634-8790"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1115 N FRONTAGE RD",
            "city": "VICKSBURG",
            "state": "MS",
            "postal_code": "391805102",
            "telephone_number": "601-634-8790"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "VICKSBURG CLINIC LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-06-23",
        "last_updated": "2008-11-25",
        "status": "A",
        "authorized_official_last_name": "BREWER",
        "authorized_official_first_name": "DEBBIE",
        "authorized_official_middle_name": "T",
        "authorized_official_title_or_position": "DIRECTOR OF PROVIDER ENROLLMENT",
        "authorized_official_telephone_number": "877-892-9813"
    },
    "taxonomies": [
        {
            "code": "363L00000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207KA0200X",
            "taxonomy_group": "",
            "desc": "Allergy & Immunology, Allergy",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207RC0000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Cardiovascular Disease",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207RI0200X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Infectious Disease",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "207RP1001X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Pulmonary Disease",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207VX0000X",
            "taxonomy_group": "",
            "desc": "Obstetrics & Gynecology, Obstetrics",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207X00000X",
            "taxonomy_group": "",
            "desc": "Orthopaedic Surgery",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "2084N0400X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Neurology",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208600000X",
            "taxonomy_group": "",
            "desc": "Surgery",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208800000X",
            "taxonomy_group": "",
            "desc": "Urology",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "09015546",
            "state": "MS"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "09015547",
            "state": "MS"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00720204",
            "state": "MS"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1111716",
            "state": "LA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "09015545",
            "state": "MS"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "09015549",
            "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 Nov 25, 2008; 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.