Healthcare Provider Details

I. General information

NPI: 1205858263
Provider Name (Legal Business Name): INTERNAL MEDICINE CLINIC OF COLUMBIA, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 02/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

914 SUMRALL RD
COLUMBIA MS
39429-2652
US

IV. Provider business mailing address

914 SUMRALL RD
COLUMBIA MS
39429-2652
US

V. Phone/Fax

Practice location:
  • Phone: 601-731-1470
  • Fax: 601-731-1474
Mailing address:
  • Phone: 601-731-1470
  • Fax: 601-731-1474

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: BRYAN F MCCRAW
Title or Position: PRESIDENT
Credential: M.D.
Phone: 601-731-1470