Provider Demographics
NPI:1255692356
Name:NORTH MISSISSIPPI FACULTY PRACTICE PLAN LLC
Entity Type:Organization
Organization Name:NORTH MISSISSIPPI FACULTY PRACTICE PLAN LLC
Other - Org Name:FAMILY MEDICINE RESIDENCY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:
Authorized Official - Last Name:KIMBROUGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-377-4685
Mailing Address - Street 1:1665 S GREEN ST
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38804-6556
Mailing Address - Country:US
Mailing Address - Phone:662-377-2189
Mailing Address - Fax:662-377-2263
Practice Address - Street 1:1665 S GREEN ST
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38804-6556
Practice Address - Country:US
Practice Address - Phone:662-377-2189
Practice Address - Fax:662-377-2263
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTH MISSISSIPPI FACULTY PRACTICE PLAN LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-06-05
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty