Provider Demographics
NPI:1902054679
Name:FAMILY CLINIC,PLLC
Entity type:Organization
Organization Name:FAMILY CLINIC,PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:MCNALLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MPH
Authorized Official - Phone:228-896-5195
Mailing Address - Street 1:350 COWAN RD
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39507-2008
Mailing Address - Country:US
Mailing Address - Phone:228-896-5195
Mailing Address - Fax:228-897-2395
Practice Address - Street 1:350 COWAN RD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39507-2008
Practice Address - Country:US
Practice Address - Phone:228-896-5195
Practice Address - Fax:228-897-2395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-05
Last Update Date:2013-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11462261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS080000366Medicare PIN