Provider Demographics
NPI:1811234636
Name:WESTSIDE FAMILY MEDICAL CLINIC PLLC
Entity Type:Organization
Organization Name:WESTSIDE FAMILY MEDICAL CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:LARRY
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:662-375-9810
Mailing Address - Street 1:2372 HIGHWAY 49 EAST
Mailing Address - Street 2:
Mailing Address - City:SUMNER
Mailing Address - State:MS
Mailing Address - Zip Code:38957
Mailing Address - Country:US
Mailing Address - Phone:662-375-9310
Mailing Address - Fax:662-375-9311
Practice Address - Street 1:2372 MS HIGHWAY 49 EAST
Practice Address - Street 2:
Practice Address - City:SUMNER
Practice Address - State:MS
Practice Address - Zip Code:38957
Practice Address - Country:US
Practice Address - Phone:662-375-9310
Practice Address - Fax:662-375-9311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-14
Last Update Date:2013-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR853452261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0123085Medicaid
MS0123085Medicaid