Provider Demographics
NPI:1285818005
Name:RIDGELAND FAMILY MEDICAL CTR
Entity type:Organization
Organization Name:RIDGELAND FAMILY MEDICAL CTR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:DURR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-856-9980
Mailing Address - Street 1:305 HIGHWAY 51
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-3428
Mailing Address - Country:US
Mailing Address - Phone:601-856-9980
Mailing Address - Fax:601-856-9994
Practice Address - Street 1:305 HIGHWAY 51
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-3428
Practice Address - Country:US
Practice Address - Phone:601-856-9980
Practice Address - Fax:601-856-9994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-28
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS10806207Q00000X
MS12039207Q00000X, 261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSCB6301OtherRAILROAD MEDICARE
MSCB6301OtherRAILROAD MEDICARE