Provider Demographics
NPI:1568800688
Name:PREMIER MEDICAL CLINIC OF GREENVILLE PC
Entity Type:Organization
Organization Name:PREMIER MEDICAL CLINIC OF GREENVILLE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:
Authorized Official - Last Name:COLBERT
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:662-332-8848
Mailing Address - Street 1:PO BOX 4577
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38704-4577
Mailing Address - Country:US
Mailing Address - Phone:662-332-8848
Mailing Address - Fax:662-332-8854
Practice Address - Street 1:1504 HOSPITAL ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38703-3219
Practice Address - Country:US
Practice Address - Phone:662-378-9929
Practice Address - Fax:662-378-9926
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-11
Last Update Date:2013-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS14161261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00114839Medicaid