Provider Demographics
NPI:1619107778
Name:ANCHOR MEDICAL CLINIC PLLC
Entity Type:Organization
Organization Name:ANCHOR MEDICAL CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BYDALEK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:228-769-9155
Mailing Address - Street 1:PO BOX 1206
Mailing Address - Street 2:
Mailing Address - City:PASCAGOULA
Mailing Address - State:MS
Mailing Address - Zip Code:39568-1206
Mailing Address - Country:US
Mailing Address - Phone:228-769-9155
Mailing Address - Fax:
Practice Address - Street 1:3613B HOSPITAL ST
Practice Address - Street 2:
Practice Address - City:PASCAGOULA
Practice Address - State:MS
Practice Address - Zip Code:39581-4112
Practice Address - Country:US
Practice Address - Phone:228-769-9155
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-22
Last Update Date:2009-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06122758Medicaid
MS06122758Medicaid