Provider Demographics
NPI:1093913634
Name:UNIVERSITY FAMILY MEDICINE ASSOCIATES, PLLC
Entity Type:Organization
Organization Name:UNIVERSITY FAMILY MEDICINE ASSOCIATES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:BEEBE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-984-5404
Mailing Address - Street 1:PO BOX 4999
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39296-4999
Mailing Address - Country:US
Mailing Address - Phone:601-984-5404
Mailing Address - Fax:601-815-3771
Practice Address - Street 1:1410 E WOODROW WILSON AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-5114
Practice Address - Country:US
Practice Address - Phone:601-984-5404
Practice Address - Fax:601-815-3771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09014106Medicaid
MS09014130Medicaid
MSCA9885Medicare ID - Type UnspecifiedRAILROAD
MS09014130Medicaid