Provider Demographics
NPI:1376181990
Name:CASSIDY BAYOU MEDICAL CLINIC
Entity Type:Organization
Organization Name:CASSIDY BAYOU MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SONJA
Authorized Official - Middle Name:BUSH
Authorized Official - Last Name:PENNINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:662-375-2363
Mailing Address - Street 1:PO BOX 240
Mailing Address - Street 2:
Mailing Address - City:SUMNER
Mailing Address - State:MS
Mailing Address - Zip Code:38957-0240
Mailing Address - Country:US
Mailing Address - Phone:662-375-9310
Mailing Address - Fax:662-375-9311
Practice Address - Street 1:2372 US 49-E
Practice Address - Street 2:
Practice Address - City:SUMNER
Practice Address - State:MS
Practice Address - Zip Code:38957
Practice Address - Country:US
Practice Address - Phone:662-375-9310
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-13
Last Update Date:2020-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty