Provider Demographics
NPI:1982786745
Name:EMS CLINIC
Entity Type:Organization
Organization Name:EMS CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SR
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:662-453-0532
Mailing Address - Street 1:1509 STRONG AVE
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:38930
Mailing Address - Country:US
Mailing Address - Phone:662-455-4411
Mailing Address - Fax:662-455-9870
Practice Address - Street 1:1509 STRONG AVE
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:MS
Practice Address - Zip Code:38930
Practice Address - Country:US
Practice Address - Phone:662-455-4411
Practice Address - Fax:662-455-9870
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GREENWOOD CLINIC FOR WOMEN;PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-20
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09013939Medicaid