1770929713 NPI number — RESERVOIR FAMILY MEDICAL CLINIC, PA

Table of content: (NPI 1770929713)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770929713 NPI number — RESERVOIR FAMILY MEDICAL CLINIC, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RESERVOIR FAMILY MEDICAL CLINIC, PA
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:
1770929713
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/29/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1679 OLD FANNIN RD STE E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLOWOOD
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39232-8101
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-992-6511
Provider Business Mailing Address Fax Number:
601-992-5684

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1679 OLD FANNIN RD STE E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLOWOOD
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39232-8101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-992-6511
Provider Business Practice Location Address Fax Number:
601-992-5684
Provider Enumeration Date:
05/17/2013

Additional Information

Authorized Official

Authorized Official Last Name:
CRENSHAW
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
NAURICE
Authorized Official Title or Position:
OWNER/PHYSICAN
Authorized Official Telephone Number:
601-992-6511

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  09099 , 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)





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