Provider Demographics
NPI:1932197779
Name:GREENVILLE FAMILY MEDICAL CENTER, INC.
Entity Type:Organization
Organization Name:GREENVILLE FAMILY MEDICAL CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JOE
Authorized Official - Middle Name:S
Authorized Official - Last Name:PULLIAM
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:662-335-1621
Mailing Address - Street 1:1467 HIGHWAY 1 S
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38701-7141
Mailing Address - Country:US
Mailing Address - Phone:662-335-1621
Mailing Address - Fax:662-335-8128
Practice Address - Street 1:1467 HIGHWAY 1 S
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38701-7141
Practice Address - Country:US
Practice Address - Phone:662-335-1621
Practice Address - Fax:662-335-8128
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSC02369Medicare ID - Type Unspecified