Provider Demographics
NPI:1710216346
Name:AVALON MEDICAL LLC
Entity Type:Organization
Organization Name:AVALON MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:TOMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:DRAPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-424-9550
Mailing Address - Street 1:1413 W QUITMAN ST
Mailing Address - Street 2:
Mailing Address - City:IUKA
Mailing Address - State:MS
Mailing Address - Zip Code:38852-1130
Mailing Address - Country:US
Mailing Address - Phone:662-424-9550
Mailing Address - Fax:
Practice Address - Street 1:1413 W QUITMAN ST
Practice Address - Street 2:
Practice Address - City:IUKA
Practice Address - State:MS
Practice Address - Zip Code:38852-1130
Practice Address - Country:US
Practice Address - Phone:662-424-9550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-10
Last Update Date:2011-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04352560Medicaid
MS302G708807Medicare PIN