Provider Demographics
NPI:1396811527
Name:CLINTON FAMILY CARE LLC
Entity type:Organization
Organization Name:CLINTON FAMILY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:BRICE
Authorized Official - Last Name:WHEAT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-924-1877
Mailing Address - Street 1:309A MORRISON DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39056-5239
Mailing Address - Country:US
Mailing Address - Phone:601-924-1877
Mailing Address - Fax:601-924-1871
Practice Address - Street 1:309A MORRISON DR
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MS
Practice Address - Zip Code:39056-5239
Practice Address - Country:US
Practice Address - Phone:601-924-1877
Practice Address - Fax:601-924-1871
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS09202207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0114637Medicaid
MSP00250596 GRP DD7799OtherMEDICARE RAILROAD
MS=========OtherBLUE CROSS BLUE SHIELD
MS0114637Medicaid
MS=========OtherAHS STATE OF MISSISSIPPI
MSP00250596 GRP DD7799OtherMEDICARE RAILROAD
MS0114637Medicaid
MS=========OtherUNITED HEALTH CARE