Provider Demographics
NPI:1013312172
Name:OLD TOWNE MEDICAL LLC
Entity Type:Organization
Organization Name:OLD TOWNE MEDICAL LLC
Other - Org Name:OLD TOWNE MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:BRAME
Authorized Official - Suffix:
Authorized Official - Credentials:CFNP
Authorized Official - Phone:901-489-6595
Mailing Address - Street 1:9066 HIGHLAND ST
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-2307
Mailing Address - Country:US
Mailing Address - Phone:662-890-7717
Mailing Address - Fax:662-874-6038
Practice Address - Street 1:9066 HIGHLAND ST
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-2307
Practice Address - Country:US
Practice Address - Phone:662-890-7717
Practice Address - Fax:662-874-6038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-30
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR644986363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03278318Medicaid
MS03278318Medicaid
391568Medicare PIN