Organization
MID-SOUTH RENAL CLINIC, PLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MASHHUD M. MIRZA M.D. (PRESIDENT)
(870) 733-1177
Entity
Organization
Contact information
Practice address
1120 STATE HIGHWAY 77 STE 1, MARION, AR 72364-9046
(870) 733-1177
(870) 702-6128
Mailing address
PO BOX 55, MARION, AR 72364-0055
(870) 733-1177
(870) 702-6128
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
110217316
RAILROAD MEDICARE
—
05
—
159373002
—
AR
01
—
3154566
BLUE CROSS BLUE SHIELD
TN
01
—
5K483
BLUE CROSS BLUE SHIELD
AR
Enumeration date
08/05/2006
Last updated
05/03/2013
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