Provider Demographics
NPI:1235113069
Name:BLUE MOUNTAIN FAMILY MEDICINE CLINIC
Entity Type:Organization
Organization Name:BLUE MOUNTAIN FAMILY MEDICINE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:FORD
Authorized Official - Last Name:BARKLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-685-4700
Mailing Address - Street 1:124 NORTH GUYTON
Mailing Address - Street 2:
Mailing Address - City:BLUE MOUNTAIN
Mailing Address - State:MS
Mailing Address - Zip Code:38610
Mailing Address - Country:US
Mailing Address - Phone:662-685-4700
Mailing Address - Fax:662-685-9999
Practice Address - Street 1:124 NORTH GUYTON
Practice Address - Street 2:
Practice Address - City:BLUE MOUNTAIN
Practice Address - State:MS
Practice Address - Zip Code:38610
Practice Address - Country:US
Practice Address - Phone:662-685-4700
Practice Address - Fax:662-685-9999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-05
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09014529Medicaid
258910Medicare ID - Type Unspecified