Provider Demographics
NPI:1811008261
Name:TUTWILER CLINIC INC
Entity Type:Organization
Organization Name:TUTWILER CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR TUTWILER CLINIC IN
Authorized Official - Prefix:
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:E
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:662-345-8334
Mailing Address - Street 1:205 ALMA ST
Mailing Address - Street 2:PO BOX 462
Mailing Address - City:TUTWILER
Mailing Address - State:MS
Mailing Address - Zip Code:38963
Mailing Address - Country:US
Mailing Address - Phone:662-345-8334
Mailing Address - Fax:662-345-8336
Practice Address - Street 1:205 ALMA ST
Practice Address - Street 2:
Practice Address - City:TUTWILER
Practice Address - State:MS
Practice Address - Zip Code:38963-0462
Practice Address - Country:US
Practice Address - Phone:662-345-8334
Practice Address - Fax:662-345-8336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS10092207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09014072Medicaid
MSC02930Medicare ID - Type Unspecified
MS09014072Medicaid
E11782Medicare UPIN
253924Medicare Oscar/Certification