Basic Information
| Provider Information | |||||||||
| NPI: | 1003844978 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE GREENVILLE CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1502 S COLORADO ST | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 387037219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6623329872 | ||||||||
| FaxNumber: | 6623329878 | ||||||||
| Practice Location | |||||||||
| Address1: | 1502 S COLORADO ST | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 387037219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6623329872 | ||||||||
| FaxNumber: | 6623329878 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2006 | ||||||||
| LastUpdateDate: | 02/11/2008 | ||||||||
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| AuthorizedOfficialLastName: | PERKINS | ||||||||
| AuthorizedOfficialFirstName: | VANESSA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATIVE ASSISTANT | ||||||||
| AuthorizedOfficialTelephone: | 6623798141 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 2500316731 | 01 | MS | CLIA | OTHER | 9014413 | 05 | MS | MEDICAID | CD3504 | 01 | MS | RAILROAD MEDICARE | OTHER |