Provider Demographics
NPI:1184644007
Name:GRENADA CLINIC FOR WOMEN, PA
Entity Type:Organization
Organization Name:GRENADA CLINIC FOR WOMEN, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLDEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-226-5121
Mailing Address - Street 1:1900 GRANDVIEW DR
Mailing Address - Street 2:
Mailing Address - City:GRENADA
Mailing Address - State:MS
Mailing Address - Zip Code:38901-5066
Mailing Address - Country:US
Mailing Address - Phone:662-226-5121
Mailing Address - Fax:662-226-7529
Practice Address - Street 1:1900 GRANDVIEW DR
Practice Address - Street 2:
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901-5066
Practice Address - Country:US
Practice Address - Phone:662-226-5121
Practice Address - Fax:662-226-7529
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09014147Medicaid
MSC00612Medicare ID - Type Unspecified