Provider Demographics
NPI:1275174971
Name:ROLLING FORK MEDICAL CLINIC, LLC
Entity Type:Organization
Organization Name:ROLLING FORK MEDICAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:HEARN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-335-4105
Mailing Address - Street 1:1997 MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38703-7268
Mailing Address - Country:US
Mailing Address - Phone:662-335-4105
Mailing Address - Fax:662-335-4105
Practice Address - Street 1:44 S FOURTH ST
Practice Address - Street 2:
Practice Address - City:ROLLING FORK
Practice Address - State:MS
Practice Address - Zip Code:39159-5147
Practice Address - Country:US
Practice Address - Phone:662-335-4105
Practice Address - Fax:662-378-2879
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-03
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05457590Medicaid