Provider Demographics
NPI:1073846770
Name:PASCAGOULA URGENT CARE CENTER LLC
Entity type:Organization
Organization Name:PASCAGOULA URGENT CARE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:228-762-2044
Mailing Address - Street 1:4305 DENNY AVE
Mailing Address - Street 2:
Mailing Address - City:PASCAGOULA
Mailing Address - State:MS
Mailing Address - Zip Code:39581-5509
Mailing Address - Country:US
Mailing Address - Phone:228-762-2044
Mailing Address - Fax:
Practice Address - Street 1:4305 DENNY AVE
Practice Address - Street 2:
Practice Address - City:PASCAGOULA
Practice Address - State:MS
Practice Address - Zip Code:39581-5509
Practice Address - Country:US
Practice Address - Phone:228-762-2044
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-12
Last Update Date:2009-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13038261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1023267630OtherINDIVIDUAL NPI
F10494Medicare UPIN