Provider Demographics
NPI:1003900655
Name:BETHANY MEDICAL CLINIC
Entity Type:Organization
Organization Name:BETHANY MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHARLINE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRANDON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:662-846-5032
Mailing Address - Street 1:PO BOX 358
Mailing Address - Street 2:548 ROSEMARY ROAD
Mailing Address - City:CLEVELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38732-0358
Mailing Address - Country:US
Mailing Address - Phone:662-846-5032
Mailing Address - Fax:662-846-5034
Practice Address - Street 1:548 ROSEMARY ROAD
Practice Address - Street 2:SUITE A
Practice Address - City:CLEVELAND
Practice Address - State:MS
Practice Address - Zip Code:38732-0358
Practice Address - Country:US
Practice Address - Phone:662-846-5032
Practice Address - Fax:662-846-5034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2009-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06806279Medicaid
MS06806279Medicaid