Provider Demographics
NPI:1053684548
Name:GRENADA LAKE MEDICAL CENTER
Entity Type:Organization
Organization Name:GRENADA LAKE MEDICAL CENTER
Other - Org Name:GRENADA SPECIALTY CLINIC - TERRY PUMMER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:G
Authorized Official - Last Name:PUTT
Authorized Official - Suffix:
Authorized Official - Credentials:FACHE
Authorized Official - Phone:662-227-7000
Mailing Address - Street 1:965 AVENT DR STE 100A
Mailing Address - Street 2:
Mailing Address - City:GRENADA
Mailing Address - State:MS
Mailing Address - Zip Code:38901-5045
Mailing Address - Country:US
Mailing Address - Phone:662-227-7444
Mailing Address - Fax:662-227-7443
Practice Address - Street 1:965 AVENT DR STE 100A
Practice Address - Street 2:
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901-5045
Practice Address - Country:US
Practice Address - Phone:662-227-7444
Practice Address - Fax:662-227-7443
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GRENADA LAKE MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-02-15
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS21836207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS11516802OtherCAQH
MS00059747Medicaid
MS00059747Medicaid