Provider Demographics
NPI:1225172562
Name:GREENWOOD COMPREHENSIVE MEDICAL CLINIC
Entity Type:Organization
Organization Name:GREENWOOD COMPREHENSIVE MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VALENCIA
Authorized Official - Middle Name:PATRICE
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-455-6767
Mailing Address - Street 1:PO BOX 1179
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:38935-1179
Mailing Address - Country:US
Mailing Address - Phone:662-455-6767
Mailing Address - Fax:662-455-1774
Practice Address - Street 1:517 HIGHWAY 82 W
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:MS
Practice Address - Zip Code:38930-5030
Practice Address - Country:US
Practice Address - Phone:662-455-6767
Practice Address - Fax:662-455-1774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-19
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS10298207Q00000X
MS10035207R00000X
MSR853204363LF0000X
MSR656461363LF0000X
MSR853566363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00117378Medicaid
MS00124524Medicaid
MS06785238Medicaid
MS08327741Medicaid
MS09015021Medicaid
MS00016353Medicaid
MSP00241824Medicare PIN
MSB30135Medicare UPIN
MS00016353Medicaid
MS110016319Medicare PIN
MS080009985Medicare PIN
MS00124524Medicaid
MS302I507499Medicare PIN
MSP89690Medicare UPIN
MS09015021Medicaid
MS00117378Medicaid
MSDR8830Medicare PIN
MSS29080Medicare UPIN
MSB31095Medicare UPIN
MS08327741Medicaid
MS500000591Medicare PIN