Provider Demographics
NPI:1922171826
Name:BROOKSVILLE MEDICAL CLINIC INC
Entity Type:Organization
Organization Name:BROOKSVILLE MEDICAL CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ERNEST
Authorized Official - Middle Name:ROY
Authorized Official - Last Name:STUART
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:662-738-4424
Mailing Address - Street 1:PO BOX 348
Mailing Address - Street 2:139 N. OLIVER ST.
Mailing Address - City:BROOKSVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39739-0348
Mailing Address - Country:US
Mailing Address - Phone:662-738-4424
Mailing Address - Fax:662-738-4615
Practice Address - Street 1:139 N. OLIVER ST.
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:MS
Practice Address - Zip Code:39739-0348
Practice Address - Country:US
Practice Address - Phone:662-738-4424
Practice Address - Fax:662-738-4615
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS253912261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09014825Medicaid
MS09014825Medicaid