Provider Demographics
NPI:1174696330
Name:YAZOO CITY MEDICAL CLINIC PA
Entity type:Organization
Organization Name:YAZOO CITY MEDICAL CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:P
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-746-6083
Mailing Address - Street 1:PO BOX 1509
Mailing Address - Street 2:
Mailing Address - City:YAZOO CITY
Mailing Address - State:MS
Mailing Address - Zip Code:39194-1509
Mailing Address - Country:US
Mailing Address - Phone:662-746-6083
Mailing Address - Fax:662-746-1954
Practice Address - Street 1:805 E FIFTEENTH ST
Practice Address - Street 2:
Practice Address - City:YAZOO CITY
Practice Address - State:MS
Practice Address - Zip Code:39194-7607
Practice Address - Country:US
Practice Address - Phone:662-746-6083
Practice Address - Fax:662-746-1954
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS05855207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09012127Medicaid
MS09012127Medicaid
C00416Medicare PIN