Provider Demographics
NPI:1003300815
Name:EAST MAIN FAMILY MEDICAL CLINIC LLC
Entity Type:Organization
Organization Name:EAST MAIN FAMILY MEDICAL CLINIC LLC
Other - Org Name:ACUTE CARE FAMILY MEDICAL CLINIC OF VERONA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:RODNEY
Authorized Official - Middle Name:BRIAN
Authorized Official - Last Name:RODGERS
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:662-350-3550
Mailing Address - Street 1:5024 RAYMOND AVE
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-8671
Mailing Address - Country:US
Mailing Address - Phone:662-432-0782
Mailing Address - Fax:662-842-3061
Practice Address - Street 1:1424 E MAIN ST
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38804-2956
Practice Address - Country:US
Practice Address - Phone:662-350-3550
Practice Address - Fax:662-842-3061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-15
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR853214363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1003300815Medicaid
MS1003300815OtherCOMMERCIAL, BCBS