Provider Demographics
NPI:1669510798
Name:CALHOUN CITY MEDICAL CLINIC
Entity Type:Organization
Organization Name:CALHOUN CITY MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GUY
Authorized Official - Middle Name:R
Authorized Official - Last Name:FARMER
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:662-628-5116
Mailing Address - Street 1:PO BOX 599
Mailing Address - Street 2:
Mailing Address - City:CALHOUN CITY
Mailing Address - State:MS
Mailing Address - Zip Code:38916-0599
Mailing Address - Country:US
Mailing Address - Phone:662-628-5116
Mailing Address - Fax:662-628-5117
Practice Address - Street 1:120 BURKE - CALHOUN CITY ROAD
Practice Address - Street 2:
Practice Address - City:CALHOUN CITY
Practice Address - State:MS
Practice Address - Zip Code:38916
Practice Address - Country:US
Practice Address - Phone:662-628-5116
Practice Address - Fax:662-628-5117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS04507207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09023316Medicaid
1750492005OtherINDIVIDUAL NPI
MSB65859Medicare UPIN
MS09023316Medicaid