Provider Demographics
NPI:1528306222
Name:GOUGH'S FAMILY AND PEDIATRIC CLINIC
Entity type:Organization
Organization Name:GOUGH'S FAMILY AND PEDIATRIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:
Authorized Official - Last Name:GOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:662-745-6638
Mailing Address - Street 1:PO BOX 68
Mailing Address - Street 2:
Mailing Address - City:DREW
Mailing Address - State:MS
Mailing Address - Zip Code:38737-0068
Mailing Address - Country:US
Mailing Address - Phone:662-745-6638
Mailing Address - Fax:662-745-8480
Practice Address - Street 1:189 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DREW
Practice Address - State:MS
Practice Address - Zip Code:38737-3146
Practice Address - Country:US
Practice Address - Phone:662-745-6638
Practice Address - Fax:662-745-8480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-30
Last Update Date:2013-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS06639261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care