Provider Demographics
NPI:1316168339
Name:MEDICAL CARE CENTER, PLLC
Entity type:Organization
Organization Name:MEDICAL CARE CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JANUS
Authorized Official - Middle Name:
Authorized Official - Last Name:KULPA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:228-875-1599
Mailing Address - Street 1:3434 BIENVILLE BLVD
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-5732
Mailing Address - Country:US
Mailing Address - Phone:228-875-1599
Mailing Address - Fax:228-875-1124
Practice Address - Street 1:3434 BIENVILLE BLVD
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-5732
Practice Address - Country:US
Practice Address - Phone:228-875-1599
Practice Address - Fax:228-875-1124
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPA00086363A00000X
MSME14877207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSC03100Medicare ID - Type UnspecifiedPROVIDER NUMBER