Basic Information
| Provider Information | |||||||||
| NPI: | 1184989196 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | G A CARMICHAEL FAMILY HEALTH CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WEBSTER ELEMENTARY SCHOOL | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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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: | 622 E FOURTH ST | ||||||||
| Address2: | |||||||||
| City: | YAZOO CITY | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391943715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018595213 | ||||||||
| FaxNumber: | 6018598771 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2012 | ||||||||
| LastUpdateDate: | 07/06/2012 | ||||||||
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| AuthorizedOfficialLastName: | COTTEN | ||||||||
| AuthorizedOfficialFirstName: | PHYLLIS | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | FINANCE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6018595213 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | APPLIED FOR | 05 | MS | MEDICAID |