Provider Demographics
NPI:1679652754
Name:EMMANUEL RIDGE COMMUNITY HEALTH CLINIC
Entity Type:Organization
Organization Name:EMMANUEL RIDGE COMMUNITY HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:BEATRICE
Authorized Official - Middle Name:A
Authorized Official - Last Name:EZEM
Authorized Official - Suffix:
Authorized Official - Credentials:RN, CM, CLNC
Authorized Official - Phone:601-927-9839
Mailing Address - Street 1:2073 HIGHWAY 49 S
Mailing Address - Street 2:SUITE A
Mailing Address - City:FLORENCE
Mailing Address - State:MS
Mailing Address - Zip Code:39073-9422
Mailing Address - Country:US
Mailing Address - Phone:601-709-3301
Mailing Address - Fax:601-709-3308
Practice Address - Street 1:2073 HIGHWAY 49 S
Practice Address - Street 2:SUITE A
Practice Address - City:FLORENCE
Practice Address - State:MS
Practice Address - Zip Code:39073-9422
Practice Address - Country:US
Practice Address - Phone:601-709-3301
Practice Address - Fax:601-709-3308
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Not Answered261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Not Answered261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS16022OtherPHYSICIAN
MS00119586Medicaid
MS04036718Medicaid
MSR850959OtherFNP
MS00121128Medicaid
MS18216OtherPHYSICIAN
MSR850959OtherFNP
MSG64498Medicare UPIN