Provider Demographics
NPI:1962509208
Name:GREATER MERIDIAN HEALTH CLINIC, INC.
Entity Type:Organization
Organization Name:GREATER MERIDIAN HEALTH CLINIC, INC.
Other - Org Name:SCOOBA FAMILY MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:WILBERT
Authorized Official - Middle Name:L
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-693-0118
Mailing Address - Street 1:2701 DAVIS ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39301-5708
Mailing Address - Country:US
Mailing Address - Phone:601-693-0118
Mailing Address - Fax:601-965-0324
Practice Address - Street 1:927 KEMPER ST
Practice Address - Street 2:
Practice Address - City:SCOOBA
Practice Address - State:MS
Practice Address - Zip Code:39358-7478
Practice Address - Country:US
Practice Address - Phone:662-476-9595
Practice Address - Fax:601-965-0324
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GREATER MERIDIAN HEALTH CLINIC, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-20
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS9015889Medicaid
MS9015889Medicaid