Provider Demographics
NPI:1154733673
Name:STARFISH FAMILY PRACTICE
Entity type:Organization
Organization Name:STARFISH FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:YALTAH
Authorized Official - Last Name:MULLEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:228-396-5022
Mailing Address - Street 1:13066 SHRINERS BLVD
Mailing Address - Street 2:SUITE A AND B
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39532-8616
Mailing Address - Country:US
Mailing Address - Phone:228-396-5022
Mailing Address - Fax:228-396-5028
Practice Address - Street 1:13066 SHRINERS BLVD
Practice Address - Street 2:SUITE A AND B
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39532-8616
Practice Address - Country:US
Practice Address - Phone:228-396-5022
Practice Address - Fax:228-396-5028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-02
Last Update Date:2014-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS14226261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06103001Medicaid