Healthcare Provider Details

I. General information

NPI: 1164573176
Provider Name (Legal Business Name): WARRINGTON CLINIC, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 08/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1022 MARTIN LUTHER KING DRIVE POB 289
MARKS MS
38646
US

IV. Provider business mailing address

1022 MARTIN LUTHER KING DRIVE POB 289
MARKS MS
38646
US

V. Phone/Fax

Practice location:
  • Phone: 662-326-3500
  • Fax:
Mailing address:
  • Phone: 662-326-3500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. RICHARD EDWIN WALLER
Title or Position: VICE PRESIDENT
Credential: M.D.
Phone: 662-326-3500