NPIMap

Organization Active NPI

PSP Medical Clinic LLC

  • Rural Health Clinic/Center
  • Canton, MS
National Provider Identifier
1932144243
Registry record updated Apr 6, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
License
15405 Issued in MS
Legal business name
PSP MEDICAL CLINIC LLC
Practice address
1171 Hart St
Canton, MS 39046-4805
Phone
(601) 859-9888
Fax
(601) 859-9966
NPI assigned
Jun 19, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 6, 2021

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

Authorized official

Name
Mrs. Neelam Goel
Title
Manager
Phone
(601) 859-9888

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X 15405 MS Primary

Addresses

Primary practice location

1171 Hart St
Canton, MS 39046-4805

Mailing address

P.O. Box 607
Canton, MS 39157
Phone (601) 859-9888

Other identifiers 1

IdentifierTypeStateIssuer
25D1052898OtherMSCLIA

Other names 2

  • MADISON CANTON MEDICAL CLINIC Doing business as
  • Magnolia Medical Clinics Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MS2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20060814000125 MS Part B Supplier - Clinic/Group Practice 6406859446 Receives reassigned benefits from 13 practitioners
1 other NPI on this enrollment
Practice locations: Canton, MS; Flowood, MS; Madison, MS; Yazoo City, MS
O20061113000513 MS Part A Provider - Rural Health Clinic 6406859446 3 other NPIs on this enrollment
Practice locations: Canton, MS

Rural health clinic certification: CCN 258999

Legal name
PSP MEDICAL CLINIC LLC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Nov 12, 2007
Last certification
Oct 7, 2021
Ownership / control type
1A
Organization structure
LLCProprietary
Incorporated
Jul 29, 2002 in MS
Enrollment address
1171 Hart St
Canton, MS 39046-4805

Other NPIs with the same Medicare PAC ID 1

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
Tax ID family
Flowood Family Clinic4 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

2629 Courthouse Cir
Ste A
Flowood, MS 39232
Phone (601) 420-4300

1082 Gluckstadt Rd
#A
Gluckstadt, MS 39110

Ownership & related parties

All disclosed owners & managing parties 1

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Parvesh K Goel Individual 5% Or Greater Direct Ownership Interest Jan 1, 2013 100%
W-2 Managing Employee Jan 1, 1998

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Practitioners & affiliated clinicians

Practitioners 20

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 20

NPI Registry JSON

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

{
    "created_epoch": "1150675200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1617667200000",
    "number": "1932144243",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "P.O. BOX 607",
            "city": "CANTON",
            "state": "MS",
            "postal_code": "39157",
            "telephone_number": "601-859-9888",
            "fax_number": "601-859-9966"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1171 HART ST",
            "city": "CANTON",
            "state": "MS",
            "postal_code": "390464805",
            "telephone_number": "601-859-9888",
            "fax_number": "601-859-9966"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PSP MEDICAL CLINIC LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-06-19",
        "last_updated": "2021-04-06",
        "certification_date": "2021-04-06",
        "status": "A",
        "authorized_official_last_name": "GOEL",
        "authorized_official_first_name": "NEELAM",
        "authorized_official_title_or_position": "MANAGER",
        "authorized_official_telephone_number": "601-859-9888",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "MS",
            "license": "15405",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CLIA",
            "identifier": "25D1052898",
            "state": "MS"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "MADISON CANTON MEDICAL CLINIC",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "MADISON CANTON MEDICAL CLINIC",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Magnolia Medical Clinics",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Canton, MS

Sources for this page

Verify at the official NPI Registry.