1134174154 NPI number — FAMILY MEDICAL CLINIC OF NORTH MS INC

Table of content: (NPI 1134174154)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134174154 NPI number — FAMILY MEDICAL CLINIC OF NORTH MS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY MEDICAL CLINIC OF NORTH MS INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134174154
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/06/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3451 GOODMAN RD
Provider Second Line Business Mailing Address:
STE 115
Provider Business Mailing Address City Name:
SOUTHAVEN
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38672-9304
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-890-5555
Provider Business Mailing Address Fax Number:
662-890-8899

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3451 GOODMAN RD
Provider Second Line Business Practice Location Address:
STE 115
Provider Business Practice Location Address City Name:
SOUTHAVEN
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38672-9304
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-890-5555
Provider Business Practice Location Address Fax Number:
662-890-8899
Provider Enumeration Date:
05/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SKINNER
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
L
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
662-850-5555

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: CK6296 . This is a "PALMETTO" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: CK6296 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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