Basic Information
| Provider Information | |||||||||
| NPI: | 1124185129 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | G A CARMICHAEL FAMILY HEALTH CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 588 | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 390460588 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018595213 | ||||||||
| FaxNumber: | 6018598771 | ||||||||
| Practice Location | |||||||||
| Address1: | 1421 E PEACE ST STE B | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 390464938 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018552516 | ||||||||
| FaxNumber: | 6018598771 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2007 | ||||||||
| LastUpdateDate: | 02/08/2008 | ||||||||
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| AuthorizedOfficialLastName: | COTTEN | ||||||||
| AuthorizedOfficialFirstName: | PHYLLIS | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | ASST FINANCE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6018595213 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 03971398 | 05 | MS | MEDICAID |