Healthcare Provider Details

I. General information

NPI: 1912200460
Provider Name (Legal Business Name): AMORY HMA PHYSICIAN MGMT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2010
Last Update Date: 04/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

607 EARL FRYE BLVD # A
AMORY MS
38821-5503
US

IV. Provider business mailing address

123 MAIN ST N
AMORY MS
38821-3416
US

V. Phone/Fax

Practice location:
  • Phone: 662-256-6191
  • Fax: 662-256-6194
Mailing address:
  • Phone: 662-256-7112
  • Fax: 662-256-7116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number11876
License Number StateMS

VIII. Authorized Official

Name: KATHY LINLEY
Title or Position: ADMIN ASSISTANT
Credential:
Phone: 662-256-7112