Basic Information
| Provider Information | |||||||||
| NPI: | 1487196515 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | G.A. CARMICHAEL FAMILY HEALTH CENTER, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10340 HIGHWAY 433 W | ||||||||
| Address2: | |||||||||
| City: | BENTONIA | ||||||||
| State: | MS | ||||||||
| PostalCode: | 390409416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018595213 | ||||||||
| FaxNumber: | 6018598771 | ||||||||
| Practice Location | |||||||||
| Address1: | 10340 HIGHWAY 433 W | ||||||||
| Address2: | |||||||||
| City: | BENTONIA | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6627552518 | ||||||||
| FaxNumber: | 6018598771 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2016 | ||||||||
| LastUpdateDate: | 06/25/2018 | ||||||||
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| AuthorizedOfficialLastName: | COLEMAN | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6018595213 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | ED. D | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | MS | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 09207040 | 05 | MS | MEDICAID |