Provider Demographics
NPI:1902013584
Name:MAGEE AFTER HOURS CLINIC PLLC
Entity Type:Organization
Organization Name:MAGEE AFTER HOURS CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:PRUITT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-849-1230
Mailing Address - Street 1:376 SIMPSON HIGHWAY 149 # A
Mailing Address - Street 2:
Mailing Address - City:MAGEE
Mailing Address - State:MS
Mailing Address - Zip Code:39111-3409
Mailing Address - Country:US
Mailing Address - Phone:601-849-1230
Mailing Address - Fax:601-849-1890
Practice Address - Street 1:376 SIMPSON HIGHWAY 149 # A
Practice Address - Street 2:
Practice Address - City:MAGEE
Practice Address - State:MS
Practice Address - Zip Code:39111-3409
Practice Address - Country:US
Practice Address - Phone:601-849-1230
Practice Address - Fax:601-849-1890
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPA024363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04874839Medicaid
MS258970Medicare ID - Type UnspecifiedMAGEE AFTER HOURS CLINIC