NPIMap

Organization Active NPI

Mississippi Asthma & Allergy Clinic PA

  • Allergy & Immunology Physician
  • Jackson, MS
National Provider Identifier
1902882251
Registry record updated Feb 16, 2010
On this page

Key facts

NPPES NPI Registry
Primary specialty
Allergy & Immunology PhysicianTaxonomy code 207K00000X
Legal business name
MISSISSIPPI ASTHMA & ALLERGY CLINIC PA
Practice address
1513 Lakeland Dr
Ste 100
Jackson, MS 39216-4829
Phone
(601) 354-4836
Fax
(601) 354-2619
NPI assigned
Dec 19, 2005
Last updated
Feb 16, 2010By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 16, 2010

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

Authorized official

Name
Mr. David L Moak
Title
Practice Administrator
Phone
(601) 354-4836

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Allergy & Immunology Physician 207K00000X Primary

Addresses

Primary practice location

1513 Lakeland Dr
Ste 100
Jackson, MS 39216-4829

Mailing address

1513 Lakeland Dr
Ste 101
Jackson, MS 39216-4829
Phone (601) 354-4836

Other identifiers 4

IdentifierTypeStateIssuer
P00236071OtherMSRR MEDICARE
030001646OtherMSRR MEDICARE
030002483OtherMSRR MEDICARE
030003287OtherMSRR MEDICARE

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20050629000438 MS Part B Supplier - Clinic/Group Practice 7416993522 Receives reassigned benefits from 15 practitioners
Practice locations: McComb, MS; Starkville, MS; Ridgeland, MS; Oxford, MS; Meridian, MS; Jackson, MS; Hattiesburg, MS; Diberville, MS

National Provider Directory

National Provider Directory
Tax ID family
Ms Asthma and Allergy C4 organizations share this tax ID, including this one

Other organizations with this tax ID 3

Organizations that report the same tax identification number in the National Provider Directory.

Locations

3200 Mallett Rd
Ste D3
Diberville, MS 39540
Phone (228) 392-0900

109 Millsaps Dr
Ste C
Hattiesburg, MS 39402
Phone (601) 268-5051

3720 Hardy St
Ste 20
Hattiesburg, MS 39402
Phone (601) 268-5051

1513 Lakeland Dr
Ste 100
Jackson, MS 39216
Phone (601) 354-4836

1600 N State St
Ste 201
Jackson, MS 39202
Phone (601) 354-4836

3704 Highway 39 N
Meridian, MS 39301
Phone (601) 693-0216

1190 S 18th Street Ext
Oxford, MS 38655
Phone (662) 234-0424

Practitioners & affiliated clinicians

Practitioners 17

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 17

NPI Registry JSON

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

{
    "created_epoch": "1134950400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1266278400000",
    "number": "1902882251",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1513 LAKELAND DR",
            "address_2": "STE 101",
            "city": "JACKSON",
            "state": "MS",
            "postal_code": "392164829",
            "telephone_number": "601-354-4836",
            "fax_number": "601-354-2619"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1513 LAKELAND DR",
            "address_2": "STE 100",
            "city": "JACKSON",
            "state": "MS",
            "postal_code": "392164829",
            "telephone_number": "601-354-4836",
            "fax_number": "601-354-2619"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MISSISSIPPI ASTHMA & ALLERGY CLINIC PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-12-19",
        "last_updated": "2010-02-16",
        "status": "A",
        "authorized_official_last_name": "MOAK",
        "authorized_official_first_name": "DAVID",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "PRACTICE ADMINISTRATOR",
        "authorized_official_telephone_number": "601-354-4836",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "207K00000X",
            "taxonomy_group": "",
            "desc": "Allergy & Immunology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RR MEDICARE",
            "identifier": "P00236071",
            "state": "MS"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RR MEDICARE",
            "identifier": "030001646",
            "state": "MS"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RR MEDICARE",
            "identifier": "030002483",
            "state": "MS"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RR MEDICARE",
            "identifier": "030003287",
            "state": "MS"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Jackson, MS

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 16, 2010; 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.