Provider Demographics
NPI:1851573737
Name:NEW ALBANY OB/GYN CLINIC PC
Entity Type:Organization
Organization Name:NEW ALBANY OB/GYN CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE CLERK
Authorized Official - Prefix:
Authorized Official - First Name:REGINA
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-534-0029
Mailing Address - Street 1:117 FAIRFIELD DR
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:MS
Mailing Address - Zip Code:38652-3107
Mailing Address - Country:US
Mailing Address - Phone:662-534-0029
Mailing Address - Fax:
Practice Address - Street 1:117 FAIRFIELD DR
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:MS
Practice Address - Zip Code:38652-3107
Practice Address - Country:US
Practice Address - Phone:662-534-0029
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-03
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09016189Medicaid
MS09016189Medicaid