| Mission Primary Care Clinic Pllc | |
|
1901 Mission 66 Vicksburg MS 39180-3711 | |
| (601) 636-0097 | |
| (601) 629-9969 |
| Full Name | Mission Primary Care Clinic Pllc |
|---|---|
| Speciality | Family Medicine |
| Location | 1901 Mission 66, Vicksburg, Mississippi |
| Authorized Official Name and Position | Bill Fulcher (ADM) |
| Authorized Official Contact | 6016360097 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Mission Primary Care Clinic Pllc 1901 Mission 66 Vicksburg MS 39180-3711 Ph: (601) 636-0097 | Mission Primary Care Clinic Pllc 1901 Mission 66 Vicksburg MS 39180-3711 Ph: (601) 636-0097 |
| NPI Number | 1487852018 |
|---|---|
| Provider Enumeration Date | 07/05/2007 |
| Last Update Date | 05/25/2022 |
| Medicare PECOS PAC ID | 5890764914 |
|---|---|
| Medicare Enrollment ID | O20040927000415 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1487852018 | NPI | - | NPPES |
| 04935090 | Medicaid | MS |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207Q00000X | Family Medicine | (* (Not Available)) | Primary |
| 363LF0000X | Nurse Practitioner - Family | R829001 (Mississippi) | Secondary |
| Provider Name | Denesia Yvonne Giffin |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1568490241 PECOS PAC ID: 6507832318 Enrollment ID: I20040902001248 |
| Provider Name | John R Barnes |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1205865680 PECOS PAC ID: 1355302696 Enrollment ID: I20041021000722 |
| Provider Name | Joseph L Wilson |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1568560530 PECOS PAC ID: 9537183439 Enrollment ID: I20060123000424 |
| Provider Name | Robert Lee Giffin |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1376584052 PECOS PAC ID: 3870560626 Enrollment ID: I20110215000188 |
| Provider Name | Susan A Chiarito |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1871534008 PECOS PAC ID: 3678540333 Enrollment ID: I20110301000570 |
| Provider Name | John Robert Ford |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1356363915 PECOS PAC ID: 4486836632 Enrollment ID: I20110309000056 |
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