Healthcare Provider Details

I. General information

NPI: 1831592088
Provider Name (Legal Business Name): BUDE FAMILY MEDICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2014
Last Update Date: 10/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 MAIN ST N
BUDE MS
39630-7117
US

IV. Provider business mailing address

136 MAIN ST N
BUDE MS
39630-7117
US

V. Phone/Fax

Practice location:
  • Phone: 601-384-8100
  • Fax: 601-384-4100
Mailing address:
  • Phone: 601-384-8100
  • Fax: 601-384-4100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MIKE BOLEWARE
Title or Position: ADMINISTRATOR
Credential:
Phone: 601-384-8126