Provider Demographics
NPI:1629164512
Name:TUNICA COUNTY HEALTHCARE AUTHORITY
Entity Type:Organization
Organization Name:TUNICA COUNTY HEALTHCARE AUTHORITY
Other - Org Name:TUNICA RESORTS MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC OPERATIONS OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:
Authorized Official - Last Name:CONWAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-363-3224
Mailing Address - Street 1:PO BOX 789
Mailing Address - Street 2:
Mailing Address - City:TUNICA
Mailing Address - State:MS
Mailing Address - Zip Code:38676-0789
Mailing Address - Country:US
Mailing Address - Phone:662-363-1465
Mailing Address - Fax:662-363-3215
Practice Address - Street 1:11273 U S HIGHWAY 61 NORTH
Practice Address - Street 2:
Practice Address - City:TUNICA RESORTS
Practice Address - State:MS
Practice Address - Zip Code:38664
Practice Address - Country:US
Practice Address - Phone:662-363-3224
Practice Address - Fax:662-363-3234
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2018-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
MS09015211261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015211Medicaid
MSDE5445Medicare ID - Type UnspecifiedRAILROAD MEDICARE
MS09015211Medicaid