Provider Demographics
NPI:1689786261
Name:FAMILY URGENT CARE CLINIC, PA
Entity Type:Organization
Organization Name:FAMILY URGENT CARE CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MISS
Authorized Official - First Name:EMERSON
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:CFNP
Authorized Official - Phone:662-840-8010
Mailing Address - Street 1:1154 CROSS CREEK DR
Mailing Address - Street 2:
Mailing Address - City:SALTILLO
Mailing Address - State:MS
Mailing Address - Zip Code:38866-5777
Mailing Address - Country:US
Mailing Address - Phone:662-840-8010
Mailing Address - Fax:662-840-2656
Practice Address - Street 1:1154 CROSS CREEK DR
Practice Address - Street 2:
Practice Address - City:SALTILLO
Practice Address - State:MS
Practice Address - Zip Code:38866-5777
Practice Address - Country:US
Practice Address - Phone:662-840-8010
Practice Address - Fax:662-840-2656
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
MSC02648261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Not Answered261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSC02648Medicare ID - Type UnspecifiedGROUP ID