Provider Demographics
NPI:1639621675
Name:PAS-POINT FAMILY CLINIC, LLC
Entity Type:Organization
Organization Name:PAS-POINT FAMILY CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DUNK
Authorized Official - Middle Name:A
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:228-474-2212
Mailing Address - Street 1:3736 MAIN ST
Mailing Address - Street 2:P.O. BOX 8572
Mailing Address - City:MOSS POINT
Mailing Address - State:MS
Mailing Address - Zip Code:39563-5108
Mailing Address - Country:US
Mailing Address - Phone:228-474-2242
Mailing Address - Fax:228-475-6271
Practice Address - Street 1:3736 MAIN ST
Practice Address - Street 2:
Practice Address - City:MOSS POINT
Practice Address - State:MS
Practice Address - Zip Code:39563-5108
Practice Address - Country:US
Practice Address - Phone:228-474-2242
Practice Address - Fax:228-475-6271
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-25
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
MS17210261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00113221Medicaid
MS080001855Medicare PIN