Provider Demographics
NPI:1467625665
Name:RANKIN PRIMARY CARE CLINIC, PA
Entity Type:Organization
Organization Name:RANKIN PRIMARY CARE CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:L
Authorized Official - Last Name:ELLINGSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-824-1491
Mailing Address - Street 1:PO BOX 1959
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39043-1959
Mailing Address - Country:US
Mailing Address - Phone:601-824-1491
Mailing Address - Fax:601-825-9504
Practice Address - Street 1:103 SERVICE DR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39042-2401
Practice Address - Country:US
Practice Address - Phone:601-824-1491
Practice Address - Fax:601-825-9504
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-08
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16492207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015199Medicaid