Provider Demographics
NPI:1902882251
Name:MISSISSIPPI ASTHMA & ALLERGY CLINIC PA
Entity Type:Organization
Organization Name:MISSISSIPPI ASTHMA & ALLERGY CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:L
Authorized Official - Last Name:MOAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-354-4836
Mailing Address - Street 1:1513 LAKELAND DR
Mailing Address - Street 2:STE 101
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4829
Mailing Address - Country:US
Mailing Address - Phone:601-354-4836
Mailing Address - Fax:601-354-2619
Practice Address - Street 1:1513 LAKELAND DR
Practice Address - Street 2:STE 100
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4829
Practice Address - Country:US
Practice Address - Phone:601-354-4836
Practice Address - Fax:601-354-2619
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-19
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS030002483OtherRR MEDICARE
MSP00236071OtherRR MEDICARE
MS030003287OtherRR MEDICARE
MS030001646OtherRR MEDICARE
030000037Medicare PIN
MS030003287OtherRR MEDICARE
MS030002483OtherRR MEDICARE
030000017Medicare PIN