Provider Demographics
NPI:1912088295
Name:UROLOGY CLINIC OF MERIDIAN, P.A.
Entity type:Organization
Organization Name:UROLOGY CLINIC OF MERIDIAN, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:T
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-693-1055
Mailing Address - Street 1:1302 20TH AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39301-4120
Mailing Address - Country:US
Mailing Address - Phone:601-693-1055
Mailing Address - Fax:601-482-5312
Practice Address - Street 1:1302 20TH AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-4120
Practice Address - Country:US
Practice Address - Phone:601-693-1055
Practice Address - Fax:601-482-5312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11068208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08536025Medicaid
MS08536025Medicaid
MSCM4175Medicare PIN