Provider Demographics
NPI:1093045908
Name:IMMEDIATE FAMILY CLINIC
Entity type:Organization
Organization Name:IMMEDIATE FAMILY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FNP
Authorized Official - Prefix:MR
Authorized Official - First Name:GREG
Authorized Official - Middle Name:G
Authorized Official - Last Name:PARKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:228-385-3774
Mailing Address - Street 1:2490 PASS RD
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39531-2838
Mailing Address - Country:US
Mailing Address - Phone:228-385-3774
Mailing Address - Fax:228-385-3776
Practice Address - Street 1:2490 PASS RD
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39531-2838
Practice Address - Country:US
Practice Address - Phone:228-385-3774
Practice Address - Fax:228-385-3776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-28
Last Update Date:2009-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR868142261QU0200X
MSR791344261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1811132285Medicaid
MS1255343570Medicaid