Basic Information
| Provider Information | |||||||||
| NPI: | 1619355203 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VICKSBURG CLINIC LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ONE MEDICAL PLAZA - RHC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4000 MERIDIAN BLVD | ||||||||
| Address2: | |||||||||
| City: | FRANKLIN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370676325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6154657000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 MEDICAL PLAZA DR | ||||||||
| Address2: | |||||||||
| City: | VICKSBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391805187 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018833360 | ||||||||
| FaxNumber: | 6018833364 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2015 | ||||||||
| LastUpdateDate: | 05/18/2015 | ||||||||
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| AuthorizedOfficialLastName: | WRIGHT | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR DIRECTOR PHYSICAN BUSINESS | ||||||||
| AuthorizedOfficialTelephone: | 6154657587 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.