Provider Demographics
NPI:1497096036
Name:EAST MISSISSIPPI MEDICAL CLINIC
Entity Type:Organization
Organization Name:EAST MISSISSIPPI MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAZEE
Authorized Official - Middle Name:AMEIR
Authorized Official - Last Name:AHMAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-917-0810
Mailing Address - Street 1:PO BOX 3189
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39303-3189
Mailing Address - Country:US
Mailing Address - Phone:601-635-3333
Mailing Address - Fax:601-635-3330
Practice Address - Street 1:9425 EASTSIDE DRIVE EXT
Practice Address - Street 2:SUIT A
Practice Address - City:NEWTON
Practice Address - State:MS
Practice Address - Zip Code:39345-8068
Practice Address - Country:US
Practice Address - Phone:601-635-3333
Practice Address - Fax:601-653-3330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-06
Last Update Date:2013-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS14494261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04278332Medicaid
MS04278332Medicaid
MS253808Medicare Oscar/Certification
MS930003616Medicare PIN