| Vicksburg Clinic LLC | |
|
107 Front St Ste 1200 Vidalia LA 71373-2834 | |
| (318) 336-2220 | |
| (318) 336-6060 |
| Full Name | Vicksburg Clinic LLC |
|---|---|
| Speciality | Surgery |
| Location | 107 Front St Ste 1200, Vidalia, Louisiana |
| Authorized Official Name and Position | Kristy Music (DIRECTOR PROVIDER ENROLLMENT) |
| Authorized Official Contact | 6154657377 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Vicksburg Clinic LLC 508 Broadway Delhi LA 71232-3002 Ph: (318) 878-3737 | Vicksburg Clinic LLC 107 Front St Ste 1200 Vidalia LA 71373-2834 Ph: (318) 336-2220 |
| NPI Number | 1629279054 |
|---|---|
| Provider Enumeration Date | 05/31/2007 |
| Last Update Date | 02/14/2025 |
| Certification Date | 02/14/2025 |
| Medicare PECOS PAC ID | 5890696330 |
|---|---|
| Medicare Enrollment ID | O20050322000036 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1629279054 | NPI | - | NPPES |
| 1444740 | Medicaid | LA |
| Provider Name | William Porter |
|---|---|
| Provider Type | Practitioner - Orthopedic Surgery |
| Provider Identifiers | NPI Number: 1528099413 PECOS PAC ID: 5698838423 Enrollment ID: I20240814004791 |
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