Provider Demographics
NPI:1396291944
Name:SILVER MEDICAL ASSOCIATES, LLC
Entity type:Organization
Organization Name:SILVER MEDICAL ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KIM
Authorized Official - Middle Name:ANTOINETTE
Authorized Official - Last Name:MITCHELL-SILVER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:769-242-2020
Mailing Address - Street 1:814 S HAUGH AVE
Mailing Address - Street 2:
Mailing Address - City:PICAYUNE
Mailing Address - State:MS
Mailing Address - Zip Code:39466-5350
Mailing Address - Country:US
Mailing Address - Phone:769-242-2020
Mailing Address - Fax:769-242-2023
Practice Address - Street 1:814 S HAUGH AVE
Practice Address - Street 2:BOX 1675
Practice Address - City:PICAYUNE
Practice Address - State:MS
Practice Address - Zip Code:39466-5350
Practice Address - Country:US
Practice Address - Phone:769-242-2020
Practice Address - Fax:769-242-2023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-01
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1095115261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02274570Medicaid
MS00606725Medicaid
OK20442600AMedicaid