1700994738 NPI number — GRENADA FAMILY MEDICINE CLINIC

Table of content: (NPI 1700994738)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700994738 NPI number — GRENADA FAMILY MEDICINE CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRENADA FAMILY MEDICINE CLINIC
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:
WINONA FAMILY MEDICINE CLINIC
Provider Other Organization Name Type Code:
3
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:
1700994738
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/30/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1300 SUNSET DR
Provider Second Line Business Mailing Address:
SUITE F
Provider Business Mailing Address City Name:
GRENADA
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38901-4086
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-226-5747
Provider Business Mailing Address Fax Number:
662-226-5622

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1300 SUNSET DR
Provider Second Line Business Practice Location Address:
SUITE F
Provider Business Practice Location Address City Name:
GRENADA
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38901-4086
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-226-5747
Provider Business Practice Location Address Fax Number:
662-226-5622
Provider Enumeration Date:
08/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ARMSTRONG
Authorized Official First Name:
RALPH
Authorized Official Middle Name:
C
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
662-226-5747

Provider Taxonomy Codes

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

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

  • Identifier: 09013778 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1417975731 . This is a "RALPH C ARMSTRONG, MD NPI" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 09014826 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1528086857 . This is a "RICHARD C. REID, MD NPI" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: CH9466 . This is a "RAILROAD MEDICARE GROUP" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: A12112009661880 . This is a "PECOS" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 1467470799 . This is a "KERRY TODD LEE, MD NPI" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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