Basic Information
| Provider Information | |||||||||
| NPI: | 1134155732 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PASCAGOULA FAMILY PRACTICE CLINIC PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | STE 202 | ||||||||
| Address2: | 4211 HOSPITAL STREET | ||||||||
| City: | PASCAGOULA | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395815310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2287623466 | ||||||||
| FaxNumber: | 2287626349 | ||||||||
| Practice Location | |||||||||
| Address1: | STE 202 | ||||||||
| Address2: | 4211 HOSPITAL STREET | ||||||||
| City: | PASCAGOULA | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395815310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2287623466 | ||||||||
| FaxNumber: | 2287626349 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2006 | ||||||||
| LastUpdateDate: | 01/28/2011 | ||||||||
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| AuthorizedOfficialLastName: | GROFF | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
| AuthorizedOfficialMiddleName: | HENRY | ||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 2287623466 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 09015379 | 05 | MS | MEDICAID | CH5730 | 01 | MS | RAILROAD MEDICARE | OTHER |