Provider Demographics
NPI:1447499512
Name:PATIENT FIRST URGENT CARE CLINIC, INC.
Entity type:Organization
Organization Name:PATIENT FIRST URGENT CARE CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-335-5291
Mailing Address - Street 1:1800 WATER PLACE
Mailing Address - Street 2:SUITE 222
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-2061
Mailing Address - Country:US
Mailing Address - Phone:770-953-4864
Mailing Address - Fax:770-953-8132
Practice Address - Street 1:2524 E ALEXANDER ST
Practice Address - Street 2:SUITE A
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38701-3330
Practice Address - Country:US
Practice Address - Phone:662-335-5773
Practice Address - Fax:662-335-5774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-13
Last Update Date:2009-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS10491207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C74283Medicare UPIN
MS110000195Medicare PIN