Provider Demographics
NPI:1629018478
Name:OLIVE BRANCH FAMILY MEDICAL CENTER
Entity Type:Organization
Organization Name:OLIVE BRANCH FAMILY MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-893-8484
Mailing Address - Street 1:9075 SANDIDGE CENTER CV
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-3514
Mailing Address - Country:US
Mailing Address - Phone:662-895-4949
Mailing Address - Fax:662-895-6776
Practice Address - Street 1:9075 SANDIDGE CENTER CV
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-3514
Practice Address - Country:US
Practice Address - Phone:662-895-4949
Practice Address - Fax:662-895-6776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-08
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1629018478OtherNPI