Provider Demographics
NPI:1043223340
Name:ROSEDALE FAMILY MEDICAL CENTER, P.C.
Entity Type:Organization
Organization Name:ROSEDALE FAMILY MEDICAL CENTER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:662-759-6806
Mailing Address - Street 1:P.O.BOX 310
Mailing Address - Street 2:
Mailing Address - City:ROSEDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38769-0310
Mailing Address - Country:US
Mailing Address - Phone:662-759-6806
Mailing Address - Fax:662-759-6771
Practice Address - Street 1:512 LEVEE ST.
Practice Address - Street 2:
Practice Address - City:ROSEDALE
Practice Address - State:MS
Practice Address - Zip Code:38769-0310
Practice Address - Country:US
Practice Address - Phone:662-759-6806
Practice Address - Fax:662-759-6771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-15
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS09592207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09014540Medicaid
258926Medicare ID - Type Unspecified