Provider Demographics
NPI:1508353384
Name:BAZ FAMILY MEDICAL CLINIC
Entity Type:Organization
Organization Name:BAZ FAMILY MEDICAL CLINIC
Other - Org Name:BAZ FAMILY MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDEN
Authorized Official - Prefix:
Authorized Official - First Name:JEANETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:SHABAZZ
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:717-421-5490
Mailing Address - Street 1:7922 LONGWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GAUTIER
Mailing Address - State:MS
Mailing Address - Zip Code:39553-2629
Mailing Address - Country:US
Mailing Address - Phone:717-421-5490
Mailing Address - Fax:
Practice Address - Street 1:4310 CHICOT ST
Practice Address - Street 2:
Practice Address - City:PASCAGOULA
Practice Address - State:MS
Practice Address - Zip Code:39581-4700
Practice Address - Country:US
Practice Address - Phone:717-421-5490
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-17
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR885984207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty