Provider Demographics
NPI:1477898112
Name:WOMAN'S CLINIC, A PROFESSIONAL ASSOCIATION
Entity type:Organization
Organization Name:WOMAN'S CLINIC, A PROFESSIONAL ASSOCIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KUSHNA
Authorized Official - Middle Name:K
Authorized Official - Last Name:DAMALLIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-627-7361
Mailing Address - Street 1:2000 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:CLARKSDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38614-6100
Mailing Address - Country:US
Mailing Address - Phone:662-627-7361
Mailing Address - Fax:662-627-4793
Practice Address - Street 1:2000 N STATE ST
Practice Address - Street 2:
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614-6100
Practice Address - Country:US
Practice Address - Phone:662-627-7361
Practice Address - Fax:662-627-4793
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-06
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08321779Medicaid
258977OtherRHC MEDICARE