MEDICARE: CLARKSDALE HMA PHYSICAN MANAGEMENT, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician
2	261QR1300X	Rural Health Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1063654721
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLARKSDALE HMA PHYSICAN MANAGEMENT, LLC

Provider Business Mailing Address
First Line	:	785 OHIO AVE
Second Line	:	SUITE 3G
City	:	CLARKSDALE
State	:	MS
Zip	:	38614-6217
Country	:	US
Telephone Number	:	662-624-8000
Fax Number	:	662-627-2900

Provider Business Practice Location Address
First Line	:	580 FRIARS POINT RD
Second Line	:
City	:	CLARKSDALE
State	:	MS
Zip	:	38614-9734
Country	:	US
Telephone Number	:	662-624-4316
Fax Number	:	662-621-1151

Authorized Official
Title or Position	:	AREA MANAGER
Name	:	MILLER VANCE
Credential	:
Telephone Number	:	662-624-8000

Provider Enumeration Date	:	03/27/2009
Last Update Date	:	12/23/2013

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