Provider Demographics
NPI:1689821126
Name:GREENE COUNTY FAMILY MEDICAL CLINIC
Entity Type:Organization
Organization Name:GREENE COUNTY FAMILY MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:FENDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-947-8181
Mailing Address - Street 1:PO BOX 1007
Mailing Address - Street 2:
Mailing Address - City:LUCEDALE
Mailing Address - State:MS
Mailing Address - Zip Code:39452-1007
Mailing Address - Country:US
Mailing Address - Phone:601-947-1332
Mailing Address - Fax:601-947-1331
Practice Address - Street 1:1017 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:LEAKESVILLE
Practice Address - State:MS
Practice Address - Zip Code:39451-9105
Practice Address - Country:US
Practice Address - Phone:601-394-2820
Practice Address - Fax:601-394-2827
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-27
Last Update Date:2019-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11343261QC1500X
261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00118573Medicaid
MS258544OtherMEDICARE TRSIPAN
MS00118573Medicaid