Provider Demographics
NPI:1104383389
Name:PREMIER FAMILY AND URGENT CARE
Entity type:Organization
Organization Name:PREMIER FAMILY AND URGENT CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:HICKS-ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:662-840-4577
Mailing Address - Street 1:2394 MCCULLOUGH BLVD
Mailing Address - Street 2:
Mailing Address - City:BELDEN
Mailing Address - State:MS
Mailing Address - Zip Code:38826-9579
Mailing Address - Country:US
Mailing Address - Phone:662-269-1774
Mailing Address - Fax:844-465-9102
Practice Address - Street 1:2394 MCCULLOUGH BLVD
Practice Address - Street 2:
Practice Address - City:BELDEN
Practice Address - State:MS
Practice Address - Zip Code:38826-9579
Practice Address - Country:US
Practice Address - Phone:622-053-0236
Practice Address - Fax:844-465-9102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-25
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03403770Medicaid