Provider Demographics
NPI:1871863233
Name:COMPREHENSIVE FAMILY MEDICAL CENTER, LLC
Entity Type:Organization
Organization Name:COMPREHENSIVE FAMILY MEDICAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:POLITI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-280-3428
Mailing Address - Street 1:3040 GOODMAN RD W
Mailing Address - Street 2:
Mailing Address - City:HORN LAKE
Mailing Address - State:MS
Mailing Address - Zip Code:38637-1189
Mailing Address - Country:US
Mailing Address - Phone:662-280-3428
Mailing Address - Fax:662-280-1736
Practice Address - Street 1:3040 GOODMAN RD W
Practice Address - Street 2:
Practice Address - City:HORN LAKE
Practice Address - State:MS
Practice Address - Zip Code:38637-1189
Practice Address - Country:US
Practice Address - Phone:662-280-3428
Practice Address - Fax:662-280-1736
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-03
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS18992207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1104813625OtherCOMMERCIAL