1952323073 NPI number — PRATT FAMILY MEDICAL CLINIC, P.A.

Table of content: (NPI 1952323073)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952323073 NPI number — PRATT FAMILY MEDICAL CLINIC, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRATT FAMILY MEDICAL CLINIC, P.A.
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:
PRATT FAMILY MEDICAL CLINIC, INC.
Provider Other Organization Name Type Code:
4
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:
1952323073
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/23/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
121 PRATT DRIVE
Provider Second Line Business Mailing Address:
SUITE 1 A
Provider Business Mailing Address City Name:
CORINTH
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38834
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-286-0088
Provider Business Mailing Address Fax Number:
662-286-0067

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
121 PRATT DRIVE
Provider Second Line Business Practice Location Address:
SUITE 1 A
Provider Business Practice Location Address City Name:
CORINTH
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38834
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-286-0088
Provider Business Practice Location Address Fax Number:
662-286-0067
Provider Enumeration Date:
07/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PRATT
Authorized Official First Name:
ANITA
Authorized Official Middle Name:
S.
Authorized Official Title or Position:
CLINIC ADMINISTRATOR
Authorized Official Telephone Number:
662-286-0088

Provider Taxonomy Codes

  • Taxonomy code: 207PE0004X , with the licence number:  18218 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 11767 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LF0000X , with the licence number: R865946 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: R865725 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: R649279 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: R582662 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 05206512 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: DB9549 . This is a "RAILROAD MEDICARE ID." identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: DB9549 . This is a "RAILROAD MEDICARE #" identifier . This identifiers is of the category "OTHER".
  • Identifier: 425-11-1019B . This is a "BLUE CROSS/BLUE SHIELD ID" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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