Magee After Hours Clinic PLLC
Organization Active NPI Physician Assistant · Magee, MS
NPI 1902013584 · NPPES record last updated Aug 22, 2020
Key facts
- NPI
- 1902013584
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Physician Assistant 363A00000X
- License
- PA024 (MS)
- Legal business name
- MAGEE AFTER HOURS CLINIC PLLC
- Practice address
- 376 Simpson Highway 149 # a
Magee, MS 39111-3409 - Phone
- (601) 849-1230
- Fax
- (601) 849-1890
- NPI assigned
- May 16, 2007
- Organization subpart
- No
Authorized official
- Name
- Dr. Charles Pruitt, M.D.
- Title
- Doctor
- Phone
- (601) 849-1230
Owners & managing parties with NPI records 2
-
Charles Pruitt, M.D.
-
Rudolph S Runnels Sr., M.D.
Practitioners 5
-
Debra Mims Develin, CRNP
-
Jessica April Garner, CRNP
-
Jonathan Adam Giangrosso, FNP-BC
-
David Shane Johnson, PA-C
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 25D2028484 | Magee After Hours Clinic | Certificate of waiver | Aug 16, 2027 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in MS
Rural health clinic certification: CCN 258970
- Legal name
- MAGEE AFTER HOURS CLINIC PLLC
- Doing business as
- MAGEE AFTER HOURS CLINIC
- Certification status
- Terminated Voluntary: merger or closure, Aug 31, 2025
- Provider type (POS)
- Rural health clinic
- Participating since
- Jan 1, 2004
- Last certification
- Mar 20, 2024
- Ownership / control type
- 1B
- Organization structure
- Partnership · Proprietary
- Incorporated
- Sep 16, 2002 in MS
- Enrollment address
- 376 Simpson Highway 149
Ste 300
Magee, MS 39111-3569
All disclosed owners & managing parties 3
| Name | Role | Since | Share |
|---|---|---|---|
| Rudolph S Runnels |
5% Or Greater Direct Ownership Interest | Sep 28, 2002 | |
| Patrick Pasco |
5% Or Greater Direct Ownership Interest | Sep 28, 2002 | |
| Charles Pruitt |
5% Or Greater Direct Ownership Interest | Sep 28, 2002 | |
| W-2 Managing Employee | Sep 28, 2002 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20030607000000 | MS | Part a Provider - Rural Health Clinic | 5092625251 | Practice locations: Magee, MS |
National Provider Directory
Locations
376B Simpson Highway 149
Magee, MS 39111
Phone (601) 849-1236
376 Simpson Highway 149
#A
Magee, MS 39111
Phone (601) 849-1230
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physician Assistant |
363A00000X | PA024 | MS | Yes |
Addresses
Primary practice location
376 Simpson Highway 149 # a
Magee, MS 39111-3409
Mailing address
376 Simpson Highway 149 # a
Magee, MS 39111-3409
Phone (601) 849-1230
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 04874839 | Medicaid | MS |
Other providers in Magee, MS
- Terri Jean Keyes
- Tribia Frye Lockhart
- Helena Lott
- Criss Deann Loven
- M&D Duo Lab Services
- Magee Benevoent Association
- Magee Benevolent Assn Dba Pediatric Clinic of Magee
- Magee Benevolent Associatino
- Magee Benevolent Association
- Magee Benevolent Association
All providers in Magee, MS · Physician Assistant in Mississippi
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Aug 22, 2020. 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.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.