Provider Demographics
NPI:1891911186
Name:PHYLLIS G KOONCE
Entity Type:Organization
Organization Name:PHYLLIS G KOONCE
Other - Org Name:COTTON PLANT FAMILY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER SOLE PROVIDER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PHYLLIS
Authorized Official - Middle Name:G
Authorized Official - Last Name:KOONCE
Authorized Official - Suffix:
Authorized Official - Credentials:CFNP
Authorized Official - Phone:662-538-4111
Mailing Address - Street 1:100 COUNTY ROAD 714
Mailing Address - Street 2:
Mailing Address - City:BLUE MOUNTAIN
Mailing Address - State:MS
Mailing Address - Zip Code:38610-9743
Mailing Address - Country:US
Mailing Address - Phone:662-538-4111
Mailing Address - Fax:662-538-4128
Practice Address - Street 1:100 COUNTY ROAD 714
Practice Address - Street 2:
Practice Address - City:BLUE MOUNTAIN
Practice Address - State:MS
Practice Address - Zip Code:38610-9743
Practice Address - Country:US
Practice Address - Phone:662-538-4111
Practice Address - Fax:662-538-4128
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR125960261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06577891Medicaid
MS258973Medicare ID - Type Unspecified
MSS34270Medicare UPIN