Provider Demographics
NPI:1396806857
Name:CENTRAL MEDICAL CLINIC, P.A.
Entity type:Organization
Organization Name:CENTRAL MEDICAL CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:B
Authorized Official - Last Name:DELASHMET
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-352-7011
Mailing Address - Street 1:1190 N STATE ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-2413
Mailing Address - Country:US
Mailing Address - Phone:601-352-7011
Mailing Address - Fax:601-352-3173
Practice Address - Street 1:1190 N STATE ST
Practice Address - Street 2:SUITE 201
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2413
Practice Address - Country:US
Practice Address - Phone:601-352-7011
Practice Address - Fax:601-352-3173
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2007-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04200767Medicaid
MS04200767Medicaid