Provider Demographics
NPI:1952323073
Name:PRATT FAMILY MEDICAL CLINIC, P.A.
Entity Type:Organization
Organization Name:PRATT FAMILY MEDICAL CLINIC, P.A.
Other - Org Name:PRATT FAMILY MEDICAL CLINIC, INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANITA
Authorized Official - Middle Name:S
Authorized Official - Last Name:PRATT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-286-0088
Mailing Address - Street 1:121 PRATT DRIVE
Mailing Address - Street 2:SUITE 1 A
Mailing Address - City:CORINTH
Mailing Address - State:MS
Mailing Address - Zip Code:38834
Mailing Address - Country:US
Mailing Address - Phone:662-286-0088
Mailing Address - Fax:662-286-0067
Practice Address - Street 1:121 PRATT DRIVE
Practice Address - Street 2:SUITE 1 A
Practice Address - City:CORINTH
Practice Address - State:MS
Practice Address - Zip Code:38834
Practice Address - Country:US
Practice Address - Phone:662-286-0088
Practice Address - Fax:662-286-0067
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS18218207PE0004X
MS11767207Q00000X
MSR865946363LF0000X
MSR865725363LF0000X
MSR649279363LF0000X
MSR582662363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical ServicesGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05206512Medicaid
MSDB9549OtherRAILROAD MEDICARE ID.
DB9549OtherRAILROAD MEDICARE #
MS425-11-1019BOtherBLUE CROSS/BLUE SHIELD ID
MSDB9549OtherRAILROAD MEDICARE ID.
MSF41245Medicare UPIN