Provider Demographics
NPI:1396014395
Name:COMPREHENSIVE FAMILY MEDICAL CENTER, INC.
Entity Type:Organization
Organization Name:COMPREHENSIVE FAMILY MEDICAL CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:L
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:NP-C
Authorized Official - Phone:662-280-3428
Mailing Address - Street 1:3040 GOODMAN RD W
Mailing Address - Street 2:
Mailing Address - City:HORN LAKE
Mailing Address - State:MS
Mailing Address - Zip Code:38637-1189
Mailing Address - Country:US
Mailing Address - Phone:662-280-3428
Mailing Address - Fax:
Practice Address - Street 1:3040 GOODMAN RD W
Practice Address - Street 2:
Practice Address - City:HORN LAKE
Practice Address - State:MS
Practice Address - Zip Code:38637-1189
Practice Address - Country:US
Practice Address - Phone:662-280-3428
Practice Address - Fax:662-280-1736
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-20
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSA810353363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1134450307OtherCOMMERCIAL INSURANCE