Provider Demographics
NPI:1912058231
Name:GRENADA FAMILY MEDICINE CLINIC
Entity Type:Organization
Organization Name:GRENADA FAMILY MEDICINE CLINIC
Other - Org Name:WINONA FAMILY MEDICINE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:C
Authorized Official - Last Name:ARMSTRONG
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:662-226-5747
Mailing Address - Street 1:1300 SUNSET DR STE F
Mailing Address - Street 2:
Mailing Address - City:GRENADA
Mailing Address - State:MS
Mailing Address - Zip Code:38901-4083
Mailing Address - Country:US
Mailing Address - Phone:662-283-4433
Mailing Address - Fax:662-283-4434
Practice Address - Street 1:418B N APPLEGATE ST
Practice Address - Street 2:
Practice Address - City:WINONA
Practice Address - State:MS
Practice Address - Zip Code:38967-1827
Practice Address - Country:US
Practice Address - Phone:662-283-4433
Practice Address - Fax:662-283-4434
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GRENADA FAMILY MEDICINE CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-15
Last Update Date:2010-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1417975731OtherRALPH C ARMSTRONG, MD NPI
MSA12112009661880OtherPECOS
MSCH9466OtherRAILROAD MEDICARE GROUP
MS09014826Medicaid
MS1528086857OtherRICHARD C. REID, MD NPI
MS1467470799OtherKERRY TODD LEE, MD NPI
MS1700994738OtherGRENADA FAMILY MEDICINE CLINIC NPI
MS09014826Medicaid