Provider Demographics
NPI:1770741191
Name:GREEN TREE FAMILY MEDICAL CLINIC
Entity type:Organization
Organization Name:GREEN TREE FAMILY MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:M
Authorized Official - Last Name:BYNUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-765-3180
Mailing Address - Street 1:PO BOX 1107
Mailing Address - Street 2:
Mailing Address - City:MOUNT OLIVE
Mailing Address - State:MS
Mailing Address - Zip Code:39119-1107
Mailing Address - Country:US
Mailing Address - Phone:601-797-3405
Mailing Address - Fax:601-797-3405
Practice Address - Street 1:603 MAIN STREET
Practice Address - Street 2:
Practice Address - City:MT. OLIVE
Practice Address - State:MS
Practice Address - Zip Code:39119
Practice Address - Country:US
Practice Address - Phone:601-797-3405
Practice Address - Fax:601-797-4707
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-02
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
253911Medicare PIN