Provider Demographics
NPI:1659591428
Name:GREENVILLE PRIMARY CARE II
Entity Type:Organization
Organization Name:GREENVILLE PRIMARY CARE II
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ARVIS
Authorized Official - Middle Name:
Authorized Official - Last Name:HAWKINS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-334-1253
Mailing Address - Street 1:2363 HIGHWAY 1 S
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38701-8337
Mailing Address - Country:US
Mailing Address - Phone:662-334-1253
Mailing Address - Fax:662-332-0443
Practice Address - Street 1:2363 HIGHWAY 1 S
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38701-8337
Practice Address - Country:US
Practice Address - Phone:662-334-1253
Practice Address - Fax:662-332-0443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS08946207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09013897Medicaid
MS09013897Medicaid
MSC02036Medicare PIN