NPIMap

Organization Active NPI

Vicksburg Clinic LLC

  • Family Medicine Physician
  • Vicksburg, MS
National Provider Identifier
1790711158
Registry record updated Nov 20, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 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
Last updated
Nov 20, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 20, 2024

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

Authorized official

Name
Kristina Music
Title
Director Provider Enrollment
Phone
(615) 465-7000

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
Family Nurse Practitioner 363LF0000X
Family Medicine Physician 207Q00000X Primary
Radiation Oncology Physician 2085R0001X
General Practice Physician 208D00000X

Addresses

Primary practice location

2100 Highway 61 N
Vicksburg, MS 39183-8211

Mailing address

PO Box 689022
Franklin, TN 37068-9022

Other identifiers 3

IdentifierTypeStateIssuer
200002582MedicaidMS
1446084MedicaidLA
1444596MedicaidLA

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
Practice locations: Brandon, MS; Vicksburg, MS; Rolling Fork, MS; Port Gibson, MS; Natchez, MS; Jackson, MS; Greenville, MS; Fayette, MS…

Other NPIs with the same Medicare PAC ID 3

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

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

Locations

522 Main St
Delhi, LA 71232
Phone (318) 878-2417

10 Crothers Dr
#4
Tallulah, LA 71282
Phone (318) 574-1137

107 Front St
Ste 1107
Vidalia, LA 71373
Phone (318) 336-2218

309 Morrison Dr
Ste C
Clinton, MS 39056
Phone (601) 883-6030

2200 Highway 61 N
#2100
Vicksburg, MS 39183
Phone (601) 883-3144

2200 Highway 61 N
#2300
Vicksburg, MS 39183
Phone (601) 883-3320

2200 Highway 61 N
#2400
Vicksburg, MS 39183
Phone (601) 883-3350

2200 Highway 61 N
#3200
Vicksburg, MS 39183
Phone (601) 883-3320

2200 Highway 61 N
#3400
Vicksburg, MS 39183
Phone (601) 883-3542

4146 Washington St
Vicksburg, MS 39180

Practitioners & affiliated clinicians

Practitioners 141

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 141

NPI Registry JSON

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

{
    "created_epoch": "1151193600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1732060800000",
    "number": "1790711158",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 689022",
            "city": "FRANKLIN",
            "state": "TN",
            "postal_code": "370689022"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2100 HIGHWAY 61 N",
            "city": "VICKSBURG",
            "state": "MS",
            "postal_code": "391838211",
            "telephone_number": "601-883-5000"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "VICKSBURG CLINIC LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-06-25",
        "last_updated": "2024-11-20",
        "certification_date": "2024-11-20",
        "status": "A",
        "authorized_official_last_name": "MUSIC",
        "authorized_official_first_name": "KRISTINA",
        "authorized_official_title_or_position": "DIRECTOR PROVIDER ENROLLMENT",
        "authorized_official_telephone_number": "615-465-7000"
    },
    "taxonomies": [
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "2085R0001X",
            "taxonomy_group": "",
            "desc": "Radiology, Radiation Oncology",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208D00000X",
            "taxonomy_group": "",
            "desc": "General Practice",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200002582",
            "state": "MS"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1446084",
            "state": "LA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1444596",
            "state": "LA"
        }
    ],
    "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 20, 2024; 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.