Provider Demographics
NPI:1003092818
Name:NESHOBA FAMILY MEDICAL CLINIC
Entity Type:Organization
Organization Name:NESHOBA FAMILY MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:WEEKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-663-1367
Mailing Address - Street 1:921 W BEACON ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:MS
Mailing Address - Zip Code:39350-3229
Mailing Address - Country:US
Mailing Address - Phone:601-656-6116
Mailing Address - Fax:601-656-5445
Practice Address - Street 1:921 W BEACON ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:MS
Practice Address - Zip Code:39350-3229
Practice Address - Country:US
Practice Address - Phone:601-656-6116
Practice Address - Fax:601-656-5445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-11
Last Update Date:2008-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16407208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSC03210Medicare PIN