Provider Demographics
NPI:1518172568
Name:MOSS POINT FAMILY CLINIC
Entity Type:Organization
Organization Name:MOSS POINT FAMILY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:SIDNEY ROBERT
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:228-355-0719
Mailing Address - Street 1:5430 GRIFFIN ST
Mailing Address - Street 2:
Mailing Address - City:MOSS POINT
Mailing Address - State:MS
Mailing Address - Zip Code:39563-2003
Mailing Address - Country:US
Mailing Address - Phone:228-355-0719
Mailing Address - Fax:228-475-4039
Practice Address - Street 1:5430 GRIFFIN ST
Practice Address - Street 2:
Practice Address - City:MOSS POINT
Practice Address - State:MS
Practice Address - Zip Code:39563-2003
Practice Address - Country:US
Practice Address - Phone:228-355-0719
Practice Address - Fax:228-475-4039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-13
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS12739261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSDG3268OtherRAILROAD MEDICARE
MS1972617884OtherPERSONAL NPI NUMBER FOR M
MS0115091Medicaid
MS01903811Medicaid
MS1710955869OtherPA GRAY'S NPI
MS296723832OtherBCBS
MSF17478Medicare UPIN
MS0115091Medicaid
MS01903811Medicaid
MS0800003305Medicare NSC