Provider Demographics
NPI:1861739161
Name:KDMC PHYSICIAN CLINICS LLC
Entity type:Organization
Organization Name:KDMC PHYSICIAN CLINICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:CHRISTENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-835-9488
Mailing Address - Street 1:427 HIGHWAY 51 N
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:39601-2350
Mailing Address - Country:US
Mailing Address - Phone:601-833-6011
Mailing Address - Fax:601-823-2206
Practice Address - Street 1:950 BROOKWAY BLVD
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:MS
Practice Address - Zip Code:39601-2644
Practice Address - Country:US
Practice Address - Phone:601-823-5103
Practice Address - Fax:601-823-3514
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KINGS DAUGHTERS MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-01-08
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty