Provider Demographics
NPI:1417912486
Name:NORTH BAY FAMILY MEDICAL CLINIC, PA
Entity Type:Organization
Organization Name:NORTH BAY FAMILY MEDICAL CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:H
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:228-392-5050
Mailing Address - Street 1:15012 LEMOYNE BLVD
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39532-5205
Mailing Address - Country:US
Mailing Address - Phone:228-392-5050
Mailing Address - Fax:228-392-9168
Practice Address - Street 1:15012 LEMOYNE BLVD
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39532-5205
Practice Address - Country:US
Practice Address - Phone:228-392-5050
Practice Address - Fax:228-392-9168
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-20
Last Update Date:2008-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS009015002Medicaid
MS009015002Medicaid
MSC00233Medicare PIN