Provider Demographics
NPI:1780772780
Name:WELLS MEDICAL CLINIC INC
Entity type:Organization
Organization Name:WELLS MEDICAL CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF WELLS MEDICAL CLINIC
Authorized Official - Prefix:
Authorized Official - First Name:WILLIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:WELLS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-983-2151
Mailing Address - Street 1:PO BOX 902
Mailing Address - Street 2:
Mailing Address - City:BRUCE
Mailing Address - State:MS
Mailing Address - Zip Code:38915
Mailing Address - Country:US
Mailing Address - Phone:662-983-2151
Mailing Address - Fax:662-983-7151
Practice Address - Street 1:407 EAST CALHOUN ST
Practice Address - Street 2:
Practice Address - City:BRUCE
Practice Address - State:MS
Practice Address - Zip Code:38915
Practice Address - Country:US
Practice Address - Phone:662-983-2151
Practice Address - Fax:662-983-7151
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS09661207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015158Medicaid
B31099Medicare UPIN