Provider Demographics
NPI:1750447926
Name:EAST METRO FAMILY MEDICAL CLINIC
Entity Type:Organization
Organization Name:EAST METRO FAMILY MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DON
Authorized Official - Middle Name:A
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-932-5060
Mailing Address - Street 1:811 HIGHWAY 49 S
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:MS
Mailing Address - Zip Code:39218-9408
Mailing Address - Country:US
Mailing Address - Phone:601-932-5060
Mailing Address - Fax:601-932-5062
Practice Address - Street 1:811 HIGHWAY 49 S
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:MS
Practice Address - Zip Code:39218-9408
Practice Address - Country:US
Practice Address - Phone:601-932-5060
Practice Address - Fax:601-932-5062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-29
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS07980170100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes170100000XOther Service ProvidersMedical Genetics, Ph.D. Medical GeneticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04457077Medicaid
MS080004336Medicare PIN
MSD73529Medicare UPIN