Healthcare Provider Details

I. General information

NPI: 1215193933
Provider Name (Legal Business Name): THE CLINIC AT ELM LAKE, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2008
Last Update Date: 08/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3700 N FRONTAGE RD
COLUMBUS MS
39701
US

IV. Provider business mailing address

3700 N FRONTAGE RD
COLUMBUS MS
39701
US

V. Phone/Fax

Practice location:
  • Phone: 662-240-9999
  • Fax: 662-241-5451
Mailing address:
  • Phone: 662-240-9999
  • Fax: 662-241-5451

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License NumberMS13926
License Number StateMS

VIII. Authorized Official

Name: MRS. ANNMARIE STOKES
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 662-240-9999