Provider Demographics
NPI:1891972022
Name:FLOWOOD FAMILY MEDICINE, PLLC
Entity Type:Organization
Organization Name:FLOWOOD FAMILY MEDICINE, PLLC
Other - Org Name:MEDICAL WELLNESS AND NUTRITION CENTER OF MS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:M
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-939-4008
Mailing Address - Street 1:1 LAYFAIR DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-9717
Mailing Address - Country:US
Mailing Address - Phone:601-939-4008
Mailing Address - Fax:601-939-4010
Practice Address - Street 1:1 LAYFAIR DR
Practice Address - Street 2:SUITE 100
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9717
Practice Address - Country:US
Practice Address - Phone:601-939-4008
Practice Address - Fax:601-939-4010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-30
Last Update Date:2009-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS19643207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DO4168OtherMEDICARE RR
MS03136371Medicaid
512G700142Medicare PIN