Provider Demographics
NPI:1124459136
Name:ST MICHAELS URGENT CARE OF HATTIESBURG
Entity type:Organization
Organization Name:ST MICHAELS URGENT CARE OF HATTIESBURG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALLING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARVA
Authorized Official - Middle Name:JOYCE
Authorized Official - Last Name:COOLEY
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:601-909-2539
Mailing Address - Street 1:3700 HARDY ST
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-1610
Mailing Address - Country:US
Mailing Address - Phone:601-602-2014
Mailing Address - Fax:601-602-2015
Practice Address - Street 1:3700 HARDY ST
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-1610
Practice Address - Country:US
Practice Address - Phone:601-602-2014
Practice Address - Fax:601-602-2015
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INLAND FAMILY PRACTICE CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-12-02
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
MSR875464363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00776879Medicaid
MS6709560001Medicare NSC
MS00776879Medicaid
MS00776879Medicaid
MS302G702911Medicare PIN