Provider Demographics
NPI:1134347958
Name:CLEVELAND MEDICAL CLINIC PLLC
Entity type:Organization
Organization Name:CLEVELAND MEDICAL CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TOMMICILE
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-843-3606
Mailing Address - Street 1:PO BOX 1629
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38732-1629
Mailing Address - Country:US
Mailing Address - Phone:662-843-3606
Mailing Address - Fax:662-846-1194
Practice Address - Street 1:810 E SUNFLOWER RD
Practice Address - Street 2:SUITE 100A
Practice Address - City:CLEVELAND
Practice Address - State:MS
Practice Address - Zip Code:38732-2800
Practice Address - Country:US
Practice Address - Phone:662-843-3606
Practice Address - Fax:662-846-1194
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08803095Medicaid
MS08803095Medicaid