Provider Demographics
NPI:1629282330
Name:WOODLAND CLINIC LLC
Entity Type:Organization
Organization Name:WOODLAND CLINIC LLC
Other - Org Name:WOODLAND CLINIC LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-456-0111
Mailing Address - Street 1:PO BOX 186
Mailing Address - Street 2:
Mailing Address - City:WOODLAND
Mailing Address - State:MS
Mailing Address - Zip Code:39776-0186
Mailing Address - Country:US
Mailing Address - Phone:662-456-0111
Mailing Address - Fax:662-456-7335
Practice Address - Street 1:120 MARKET ST
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:MS
Practice Address - Zip Code:39776-9104
Practice Address - Country:US
Practice Address - Phone:662-456-0111
Practice Address - Fax:662-456-7335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2011-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0112415Medicaid
MS0114346Medicaid
MS09014809Medicaid
MSS69279Medicare UPIN
MS258937Medicare Oscar/Certification
MS0112415Medicaid