Provider Demographics
NPI:1083786727
Name:CARY N METTETAL
Entity type:Organization
Organization Name:CARY N METTETAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-487-0004
Mailing Address - Street 1:401 E LEE ST
Mailing Address - Street 2:
Mailing Address - City:SARDIS
Mailing Address - State:MS
Mailing Address - Zip Code:38666-1227
Mailing Address - Country:US
Mailing Address - Phone:662-487-0004
Mailing Address - Fax:662-487-0006
Practice Address - Street 1:401 E LEE ST
Practice Address - Street 2:
Practice Address - City:SARDIS
Practice Address - State:MS
Practice Address - Zip Code:38666-1227
Practice Address - Country:US
Practice Address - Phone:662-487-0004
Practice Address - Fax:662-487-0006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015623Medicaid
MSG89335Medicare UPIN
C02918Medicare ID - Type Unspecified