Provider Demographics
NPI:1457554479
Name:INTERNAL MEDICINE CLINIC OF CLARKSDALE
Entity Type:Organization
Organization Name:INTERNAL MEDICINE CLINIC OF CLARKSDALE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:BLOUNT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-624-5481
Mailing Address - Street 1:1967 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38614-7203
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1967 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614-7203
Practice Address - Country:US
Practice Address - Phone:662-624-5481
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-07
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16074174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00119669Medicaid
MS07922048Medicaid