# VICKSBURG CLINIC LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1659307791
- **Authorized official:** DEBBIE T BREWER (DIRECTOR OF PROVIDER ENROLLMENT)
- **Authorized official phone:** (877) 892-9813

## Contact information

- **Practice address:** 1115 N FRONTAGE RD, VICKSBURG, MS 39180-5102
- **Practice address phone:** (601) 634-8790
- **Mailing address:** 1115 N FRONTAGE RD, VICKSBURG, MS 39180-5102
- **Mailing address phone:** (601) 634-8790

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207KA0200X | Allergy Physician | — | NULL | — |
| 207KA0200X | Allergy Physician | — | — | — |
| 207Q00000X | Family Medicine Physician | — | NULL | — |
| 207Q00000X | Family Medicine Physician | — | — | — |
| 207R00000X | Internal Medicine Physician | — | NULL | — |
| 207R00000X | Internal Medicine Physician | — | — | — |
| 207RC0000X | Cardiovascular Disease Physician | — | NULL | — |
| 207RC0000X | Cardiovascular Disease Physician | — | — | — |
| 207RI0200X | Infectious Disease Physician | — | NULL | Yes |
| 207RI0200X | Infectious Disease Physician | — | — | Yes |
| 207RP1001X | Pulmonary Disease Physician | — | NULL | — |
| 207RP1001X | Pulmonary Disease Physician | — | — | — |
| 207VX0000X | Obstetrics Physician | — | NULL | — |
| 207VX0000X | Obstetrics Physician | — | — | — |
| 207X00000X | Orthopaedic Surgery Physician | — | NULL | — |
| 207X00000X | Orthopaedic Surgery Physician | — | — | — |
| 208000000X | Pediatrics Physician | — | NULL | — |
| 208000000X | Pediatrics Physician | — | — | — |
| 2084N0400X | Neurology Physician | — | NULL | — |
| 2084N0400X | Neurology Physician | — | — | — |
| 208600000X | Surgery Physician | — | NULL | — |
| 208600000X | Surgery Physician | — | — | — |
| 208800000X | Urology Physician | — | NULL | — |
| 208800000X | Urology Physician | — | — | — |
| 363L00000X | Nurse Practitioner | — | NULL | — |
| 363L00000X | Nurse Practitioner | — | — | — |

## Other

- **Enumeration date:** 06/23/2006
- **Last updated:** 11/25/2008