Provider Demographics
NPI:1740213180
Name:MISSISSIPPI FAMILY HEALTH CARE CENTER PA
Entity type:Organization
Organization Name:MISSISSIPPI FAMILY HEALTH CARE CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VENUS
Authorized Official - Middle Name:JEANETTE
Authorized Official - Last Name:CALLAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:228-696-0230
Mailing Address - Street 1:1820 OLD MOBILE AVE
Mailing Address - Street 2:
Mailing Address - City:PASCAGOULA
Mailing Address - State:MS
Mailing Address - Zip Code:39567-4412
Mailing Address - Country:US
Mailing Address - Phone:228-696-0230
Mailing Address - Fax:228-712-2374
Practice Address - Street 1:1820 OLD MOBILE AVE
Practice Address - Street 2:
Practice Address - City:PASCAGOULA
Practice Address - State:MS
Practice Address - Zip Code:39567-4412
Practice Address - Country:US
Practice Address - Phone:228-696-0230
Practice Address - Fax:228-712-2374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09014888Medicaid
C02430Medicare ID - Type Unspecified