Provider Demographics
NPI:1174579338
Name:STATCARE PLLC
Entity type:Organization
Organization Name:STATCARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:B
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-250-1122
Mailing Address - Street 1:PO BOX 1909
Mailing Address - Street 2:
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39649-1909
Mailing Address - Country:US
Mailing Address - Phone:601-250-1122
Mailing Address - Fax:601-250-0290
Practice Address - Street 1:1017 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648-3827
Practice Address - Country:US
Practice Address - Phone:601-250-1122
Practice Address - Fax:601-250-0290
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSCN2774OtherMEDICARE RAILROAD
MSCN2774OtherMEDICARE RAILROAD