Provider Demographics
NPI:1881640142
Name:EAST MISSISSIPPI MEDICAL CLINIC, PLLC
Entity Type:Organization
Organization Name:EAST MISSISSIPPI MEDICAL CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAZEE
Authorized Official - Middle Name:AMEIR
Authorized Official - Last Name:AHMAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-485-7777
Mailing Address - Street 1:4711 POPLAR SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39305-2622
Mailing Address - Country:US
Mailing Address - Phone:601-485-7777
Mailing Address - Fax:601-485-7766
Practice Address - Street 1:4711 POPLAR SPG DR
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39305-2622
Practice Address - Country:US
Practice Address - Phone:601-485-7777
Practice Address - Fax:601-485-7766
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS14494261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00925081Medicaid
MSG10490Medicare UPIN
MS930003616Medicare PIN
MS00925081Medicaid