Provider Demographics
NPI:1497705446
Name:COCKRELL FAMILY MEDICAL CENTER PC
Entity Type:Organization
Organization Name:COCKRELL FAMILY MEDICAL CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JESSIE
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:COCKRELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-301-1128
Mailing Address - Street 1:120 NORFLEET DR
Mailing Address - Street 2:
Mailing Address - City:SENATOBIA
Mailing Address - State:MS
Mailing Address - Zip Code:38668-2220
Mailing Address - Country:US
Mailing Address - Phone:662-301-1128
Mailing Address - Fax:662-301-4430
Practice Address - Street 1:120 NORFLEET DR
Practice Address - Street 2:
Practice Address - City:SENATOBIA
Practice Address - State:MS
Practice Address - Zip Code:38668-2220
Practice Address - Country:US
Practice Address - Phone:662-301-1128
Practice Address - Fax:662-301-4430
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSM17248261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSDE7710OtherGROUP MS RAILROAD MEDICAR
MSDE7710OtherGROUP MS RAILROAD MEDICAR
MSH30758Medicare UPIN