Basic Information
| Provider Information | |||||||||
| NPI: | 1588810865 | ||||||||
| 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: | 116 N HAYDEN ST | ||||||||
| Address2: | |||||||||
| City: | BELZONI | ||||||||
| State: | MS | ||||||||
| PostalCode: | 390383932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018595213 | ||||||||
| FaxNumber: | 6018598771 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2008 | ||||||||
| LastUpdateDate: | 04/22/2014 | ||||||||
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| AuthorizedOfficialLastName: | RANSBURG | ||||||||
| AuthorizedOfficialFirstName: | NIKITA | ||||||||
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| AuthorizedOfficialTitleorPosition: | FINANCE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6018595213 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 09016048 | 05 | MS | MEDICAID |