| Revive Family Medical Clinic, Llc | |
|
3549 Bluecutt Rd Columbus MS 39705-1324 | |
| (662) 386-1541 | |
| Not Available |
| Full Name | Revive Family Medical Clinic, Llc |
|---|---|
| Speciality | Clinic/Center |
| Location | 3549 Bluecutt Rd, Columbus, Mississippi |
| Authorized Official Name and Position | Micah Alexander Grant (NURSE PRACTITIONER) |
| Authorized Official Contact | 6625704174 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Revive Family Medical Clinic, Llc 3549 Bluecutt Rd Columbus MS 39705-1324 Ph: (662) 570-4174 | Revive Family Medical Clinic, Llc 3549 Bluecutt Rd Columbus MS 39705-1324 Ph: (662) 386-1541 |
| NPI Number | 1902577554 |
|---|---|
| Provider Enumeration Date | 09/23/2021 |
| Last Update Date | 11/18/2021 |
| Medicare PECOS PAC ID | 4082002787 |
|---|---|
| Medicare Enrollment ID | O20211029001523 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1902577554 | NPI | - | NPPES |
| 06975501 | Medicaid | MS | |
| R874310 | Other | MS | MISSISSIPPI BOARD OF NURSING- RN |
| F0115273 | Other | AANP | |
| 1437558061 | Other | NPI-1 |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261Q00000X | Clinic/center | (* (Not Available)) | Primary |
| Provider Name | Micah Alexander Grant |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1437558061 PECOS PAC ID: 5991016503 Enrollment ID: I20150624000695 |
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