Provider Demographics
NPI:1235361304
Name:WEST POINT INTERNAL MEDICINE CLINIC, PA
Entity Type:Organization
Organization Name:WEST POINT INTERNAL MEDICINE CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDMUND
Authorized Official - Middle Name:ANDERSON
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:662-377-4685
Mailing Address - Street 1:830 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:WEST POINT
Mailing Address - State:MS
Mailing Address - Zip Code:39773-9319
Mailing Address - Country:US
Mailing Address - Phone:662-377-4685
Mailing Address - Fax:
Practice Address - Street 1:830 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:WEST POINT
Practice Address - State:MS
Practice Address - Zip Code:39773-9319
Practice Address - Country:US
Practice Address - Phone:662-377-4685
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-21
Last Update Date:2011-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS28771207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00115012Medicaid
C48098Medicare UPIN
110001077Medicare PIN