Provider Demographics
NPI:1629143334
Name:SOUTH RANKIN FAMILY CLINIC, LLC
Entity Type:Organization
Organization Name:SOUTH RANKIN FAMILY CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RODERICK
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:SHIELDS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-664-2273
Mailing Address - Street 1:368 SCARBROUGH ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:RICHLAND
Mailing Address - State:MS
Mailing Address - Zip Code:39218-9038
Mailing Address - Country:US
Mailing Address - Phone:601-664-2273
Mailing Address - Fax:601-664-3472
Practice Address - Street 1:368 SCARBROUGH ST
Practice Address - Street 2:SUITE B
Practice Address - City:RICHLAND
Practice Address - State:MS
Practice Address - Zip Code:39218-9038
Practice Address - Country:US
Practice Address - Phone:601-664-2273
Practice Address - Fax:601-664-3472
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS12884207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty