Provider Demographics
NPI:1598165623
Name:IMMEDIATE FAMILY CLINIC
Entity Type:Organization
Organization Name:IMMEDIATE FAMILY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PERRY
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC
Authorized Official - Phone:251-679-1988
Mailing Address - Street 1:PO BOX 4674
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39535-4674
Mailing Address - Country:US
Mailing Address - Phone:251-679-1988
Mailing Address - Fax:251-679-9282
Practice Address - Street 1:627 SARALAND BLVD S
Practice Address - Street 2:
Practice Address - City:SARALAND
Practice Address - State:AL
Practice Address - Zip Code:36571-3633
Practice Address - Country:US
Practice Address - Phone:251-679-1988
Practice Address - Fax:251-679-9282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-26
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR868142363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06381703Medicaid