Vicksburg Clinic LLC
Organization Active NPI Family Medicine Physician · Vicksburg, MS
NPI 1790711158 · NPPES record last updated Nov 20, 2024
Key facts
- NPI
- 1790711158
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Family Medicine Physician 207Q00000X
- Legal business name
- VICKSBURG CLINIC LLC
- Practice address
- 2100 Highway 61 N
Vicksburg, MS 39183-8211 - Phone
- (601) 883-5000
- NPI assigned
- Jun 25, 2006
- Organization subpart
- No
Authorized official
- Name
- Kristina Music
- Title
- Director Provider Enrollment
- Phone
- (615) 465-7000
Other NPIs on the same Medicare enrollment 3
Other NPIs with the same Medicare PAC ID 3
Practitioners 141
-
Declan F Hegarty, MD
-
Timothy P Kerut, MD
-
Miranda R McCaskill, AUD
-
Paul W Pierce IV, M.D.
-
Shelby Patricia Primeaux, MSN, APRN, AGACNP-BC
-
Adam Nicholas Protos, M.D.
-
Thomas K Sligh, MD
-
Erica Kellyn Smith, PA-C, ATC
-
Brandon Blake Teller, FNP-C
-
Thomas L Weeks, MD
-
Kenyatta Nicole Wilson, NP-C
-
Steven E Zachow, MD
-
Gustavo Barrazueta, M.D.
-
Salena Cecil, APRN
-
Feras Hamadeh, MD
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in MS
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20040116000738 | MS | Part B Supplier - Clinic/Group Practice | 5890696330 |
Receives reassigned benefits from 42 practitioners 3 other NPIs on this enrollment Practice locations: Brandon, MS; Vicksburg, MS; Rolling Fork, MS; Port Gibson, MS; Natchez, MS; Jackson, MS; Greenville, MS; Fayette, MS… |
National Provider Directory
Locations
107 Front St
Ste 1107
Vidalia, LA 71373
Phone (318) 336-2218
309 Morrison Dr
Ste C
Clinton, MS 39056
Phone (601) 883-6030
870 Main St
Ste A
Fayette, MS 39069
Phone (601) 786-3401
54 Sgt Prentiss Dr
Ste 103
Natchez, MS 39120
Phone (601) 883-5858
46 Sgt Prentiss Dr
Ste 201
Natchez, MS 39120
Phone (601) 442-3701
21 S Fourth St
#B
Rolling Fork, MS 39159
Phone (601) 883-6071
2200 Highway 61 N
Vicksburg, MS 39183
Phone (601) 883-3300
4146 Washington St
Vicksburg, MS 39180
2200 Highway 61 N
#3200
Vicksburg, MS 39183
Phone (601) 883-3320
2200 Highway 61 N
#2100
Vicksburg, MS 39183
Phone (601) 883-3144
2200 Highway 61 N
#2300
Vicksburg, MS 39183
Phone (601) 883-3320
3317 Pemberton Square Blvd
Vicksburg, MS 39180
Phone (601) 636-1173
2200 Highway 61 N
#2400
Vicksburg, MS 39183
Phone (601) 883-3350
2200 Highway 61 N
Fl 1
Vicksburg, MS 39183
Phone (601) 883-6092
2200 Highway 61 N
#3400
Vicksburg, MS 39183
Phone (601) 883-3542
1115 N Frontage Rd
Vicksburg, MS 39180
Phone (601) 634-8790
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician |
207Q00000X | Yes | ||
| Radiation Oncology Physician |
2085R0001X | |||
| General Practice Physician |
208D00000X | |||
| Family Nurse Practitioner |
363LF0000X |
Addresses
Primary practice location
2100 Highway 61 N
Vicksburg, MS 39183-8211
Mailing address
PO Box 689022
Franklin, TN 37068-9022
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 200002582 | Medicaid | MS | |
| 1444596 | Medicaid | LA | |
| 1446084 | Medicaid | LA |
Other providers in Vicksburg, MS
- Vicksburg Clinic LLC
- Vicksburg Clinic LLC
- Vicksburg Clinic LLC
- Vicksburg Clinic LLC
- Vicksburg Clinic LLC
- Vicksburg Clinic LLC
- Vicksburg Clinic LLC
- Vicksburg Clinic LLC
- Vicksburg Community Center
- Vicksburg Convalescent, LLC
All providers in Vicksburg, MS · Family Medicine Physician in Mississippi
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Nov 20, 2024. 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.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.