Provider Demographics
NPI:1568459089
Name:RIVER BEND MEDICAL CLINIC, INC
Entity Type:Organization
Organization Name:RIVER BEND MEDICAL CLINIC, INC
Other - Org Name:RIVER BEND MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAIGE
Authorized Official - Middle Name:E
Authorized Official - Last Name:KEY
Authorized Official - Suffix:
Authorized Official - Credentials:CMA XRT
Authorized Official - Phone:601-933-1199
Mailing Address - Street 1:2659 LAKELAND DR
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-9516
Mailing Address - Country:US
Mailing Address - Phone:601-933-1199
Mailing Address - Fax:601-933-1116
Practice Address - Street 1:2659 LAKELAND DR
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9516
Practice Address - Country:US
Practice Address - Phone:601-933-1199
Practice Address - Fax:601-933-1116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSNO LICENCE NUMBER173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015472Medicaid
MS09015472Medicaid