Provider Demographics
NPI:1124100813
Name:DURANT PRIMARY CARE CLINIC
Entity type:Organization
Organization Name:DURANT PRIMARY CARE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIAS
Authorized Official - Middle Name:
Authorized Official - Last Name:ABBOUD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-653-1002
Mailing Address - Street 1:638 NORTHWEST AVE
Mailing Address - Street 2:
Mailing Address - City:DURANT
Mailing Address - State:MS
Mailing Address - Zip Code:39063-3337
Mailing Address - Country:US
Mailing Address - Phone:662-653-1002
Mailing Address - Fax:662-653-1038
Practice Address - Street 1:638 NORTHWEST AVE
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:MS
Practice Address - Zip Code:39063-3337
Practice Address - Country:US
Practice Address - Phone:662-653-1002
Practice Address - Fax:662-653-1038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2009-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01824892Medicaid
MS09807861Medicaid
MS01824892Medicaid
MSF43174Medicare UPIN
MS09807861Medicaid