Provider Demographics
NPI:1508968421
Name:HORN LAKE FAMILY PRACTICE INC
Entity Type:Organization
Organization Name:HORN LAKE FAMILY PRACTICE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:SHEETAL
Authorized Official - Middle Name:
Authorized Official - Last Name:SHARMA
Authorized Official - Suffix:
Authorized Official - Credentials:OTHER
Authorized Official - Phone:662-342-6677
Mailing Address - Street 1:3102 GOODMAN RD W
Mailing Address - Street 2:
Mailing Address - City:HORN LAKE
Mailing Address - State:MS
Mailing Address - Zip Code:38637-1172
Mailing Address - Country:US
Mailing Address - Phone:662-342-6677
Mailing Address - Fax:662-342-1213
Practice Address - Street 1:3102 GOODMAN RD W
Practice Address - Street 2:
Practice Address - City:HORN LAKE
Practice Address - State:MS
Practice Address - Zip Code:38637-1172
Practice Address - Country:US
Practice Address - Phone:662-342-6677
Practice Address - Fax:662-342-1213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-01
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS15476207QA0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00118511Medicaid
MS9015003Medicaid
MSI36533Medicare UPIN
MS080002652Medicare ID - Type UnspecifiedDR A SHARMA MEDICARE #
MSG55248Medicare UPIN
MS00118511Medicaid
MSG55248Medicare UPIN
MSI36533Medicare UPIN