Provider Demographics
NPI:1245391135
Name:FAMILY PRACTICE CLINIC OF WATER VALLEY
Entity Type:Organization
Organization Name:FAMILY PRACTICE CLINIC OF WATER VALLEY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INTERNAL MEDICINE
Authorized Official - Prefix:
Authorized Official - First Name:JOE
Authorized Official - Middle Name:W
Authorized Official - Last Name:WALBER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-473-4050
Mailing Address - Street 1:PO BOX 643
Mailing Address - Street 2:
Mailing Address - City:WATER VALLEY
Mailing Address - State:MS
Mailing Address - Zip Code:38965
Mailing Address - Country:US
Mailing Address - Phone:662-473-4050
Mailing Address - Fax:662-473-4191
Practice Address - Street 1:606 S MAIN ST
Practice Address - Street 2:606 S MAIN ST
Practice Address - City:WATER VALLEY
Practice Address - State:MS
Practice Address - Zip Code:38965
Practice Address - Country:US
Practice Address - Phone:662-473-4050
Practice Address - Fax:662-473-4191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2007-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00119078Medicaid
MSC03268Medicare PIN
MS00119078Medicaid