Full Name | |
---|---|
Speciality | Family Medicine |
Location | 202 Main Street, Ecru, Mississippi |
Authorized Official Name and Position | Gerald Kimbrough (MANAGER) |
Authorized Official Contact | 6623774685 |
Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
Mailing Address | Practice Location Address |
---|---|
450 E President Ave Tupelo MS 38801-5599 Ph: (662) 377-4685 | 202 Main Street Ecru MS 38841 Ph: (662) 489-4345 |
NPI Number | 1477665107 |
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Provider Enumeration Date | 08/31/2006 |
Last Update Date | 08/22/2020 |
Identifier | Type | State | Issuer |
---|---|---|---|
1477665107 | NPI | - | NPPES |
09014823 | Medicaid | MS |
Taxonomy | Type | License (State) | Status |
---|---|---|---|
207Q00000X | Family Medicine | (* (Not Available)) | Primary |