Provider Demographics
NPI:1386721546
Name:FILLINGANE MEDICAL CLINIC, PA
Entity type:Organization
Organization Name:FILLINGANE MEDICAL CLINIC, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:FREIDA
Authorized Official - Middle Name:L
Authorized Official - Last Name:FILLINGANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-906-4175
Mailing Address - Street 1:PO BOX 14153
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39236-4153
Mailing Address - Country:US
Mailing Address - Phone:601-664-2424
Mailing Address - Fax:601-664-6675
Practice Address - Street 1:1021 N FLOWOOD DRIVE
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9533
Practice Address - Country:US
Practice Address - Phone:601-664-2424
Practice Address - Fax:601-664-6675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11114207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00116048Medicaid
010000077Medicare PIN
MS00116048Medicaid