Healthcare Provider Details

I. General information

NPI: 1225172562
Provider Name (Legal Business Name): GREENWOOD COMPREHENSIVE MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2007
Last Update Date: 05/22/2024
Certification Date: 05/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

517 HIGHWAY 82 W
GREENWOOD MS
38930-5030
US

IV. Provider business mailing address

PO BOX 1179
GREENWOOD MS
38935-1179
US

V. Phone/Fax

Practice location:
  • Phone: 662-455-6767
  • Fax: 662-455-1774
Mailing address:
  • Phone: 662-455-6767
  • Fax: 662-455-1774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number10298
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number10035
License Number StateMS

VIII. Authorized Official

Name: DR. VALENCIA PATRICE MARTIN
Title or Position: VICE PRESIDENT
Credential: M.D.
Phone: 662-455-6767