Provider Demographics
NPI:1013994060
Name:THE WOMAN'S CLINIC OF TUPELO
Entity type:Organization
Organization Name:THE WOMAN'S CLINIC OF TUPELO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OBGYN M.D.
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:J
Authorized Official - Last Name:CRECELIUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-844-0867
Mailing Address - Street 1:1512 MEDICAL PARK CIR
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-6560
Mailing Address - Country:US
Mailing Address - Phone:662-844-0867
Mailing Address - Fax:662-844-7086
Practice Address - Street 1:1512 MEDICAL PARK CIR
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-6560
Practice Address - Country:US
Practice Address - Phone:662-844-0867
Practice Address - Fax:662-844-7086
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00117464Medicaid
MS00126770Medicaid
MS00019541Medicaid
MSS43800Medicare UPIN
MS00126770Medicaid
MS00019541Medicaid