Healthcare Provider Details

I. General information

NPI: 1750447926
Provider Name (Legal Business Name): EAST METRO FAMILY MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2006
Last Update Date: 12/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 HIGHWAY 49 S
RICHLAND MS
39218-9408
US

IV. Provider business mailing address

811 HIGHWAY 49 S
RICHLAND MS
39218-9408
US

V. Phone/Fax

Practice location:
  • Phone: 601-932-5060
  • Fax: 601-932-5062
Mailing address:
  • Phone: 601-932-5060
  • Fax: 601-932-5062

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code170100000X
TaxonomyPh.D. Medical Genetics
License Number07980
License Number StateMS

VIII. Authorized Official

Name: DR. DON A. GIBSON
Title or Position: OWNER
Credential: M.D.
Phone: 601-932-5060