Provider Demographics
NPI:1063654721
Name:CLARKSDALE HMA PHYSICAN MANAGEMENT, LLC
Entity Type:Organization
Organization Name:CLARKSDALE HMA PHYSICAN MANAGEMENT, LLC
Other - Org Name:CAMPBELL FAMILY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AREA MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MILLER
Authorized Official - Middle Name:
Authorized Official - Last Name:VANCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-624-8000
Mailing Address - Street 1:785 OHIO AVE
Mailing Address - Street 2:SUITE 3G
Mailing Address - City:CLARKSDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38614-6217
Mailing Address - Country:US
Mailing Address - Phone:662-624-8000
Mailing Address - Fax:662-627-2900
Practice Address - Street 1:580 FRIARS POINT RD
Practice Address - Street 2:
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614-9734
Practice Address - Country:US
Practice Address - Phone:662-624-4316
Practice Address - Fax:662-621-1151
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CLARKSDALE HMA PHYSICIAN MANAGEMENT, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-03-27
Last Update Date:2013-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03426211Medicaid
MSC03472Medicare PIN