Provider Demographics
NPI:1932436813
Name:REGIONAL MEDICAL CLINIC, LLC.
Entity type:Organization
Organization Name:REGIONAL MEDICAL CLINIC, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ROY
Authorized Official - Middle Name:DUDLEY
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-943-5060
Mailing Address - Street 1:PO BOX 68
Mailing Address - Street 2:
Mailing Address - City:BASSFIELD
Mailing Address - State:MS
Mailing Address - Zip Code:39421-0068
Mailing Address - Country:US
Mailing Address - Phone:601-943-5060
Mailing Address - Fax:601-943-5888
Practice Address - Street 1:4297 HIGHWAY 42
Practice Address - Street 2:
Practice Address - City:BASSFIELD
Practice Address - State:MS
Practice Address - Zip Code:39421-4424
Practice Address - Country:US
Practice Address - Phone:601-943-5060
Practice Address - Fax:601-943-5888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-12
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13317261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00111136Medicaid
1952465619OtherPHYSICIAN NPI
1952465619OtherPHYSICIAN NPI