Provider Demographics
NPI:1043573199
Name:FONDREN MEDICAL CLINIC
Entity Type:Organization
Organization Name:FONDREN MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:LEIJUAN
Authorized Official - Last Name:LANE-FISHER
Authorized Official - Suffix:
Authorized Official - Credentials:PH,D,PA
Authorized Official - Phone:769-257-5336
Mailing Address - Street 1:4436 N STATE ST
Mailing Address - Street 2:SUITE A-1
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39206-5334
Mailing Address - Country:US
Mailing Address - Phone:769-257-5339
Mailing Address - Fax:
Practice Address - Street 1:4436 N STATE ST
Practice Address - Street 2:SUITE A-1
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39206-5334
Practice Address - Country:US
Practice Address - Phone:769-257-5339
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-22
Last Update Date:2012-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00125523Medicaid