Healthcare Provider Details

I. General information

NPI: 1285818005
Provider Name (Legal Business Name): RIDGELAND FAMILY MEDICAL CTR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2007
Last Update Date: 12/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 HIGHWAY 51
RIDGELAND MS
39157-3428
US

IV. Provider business mailing address

305 HIGHWAY 51
RIDGELAND MS
39157-3428
US

V. Phone/Fax

Practice location:
  • Phone: 601-856-9980
  • Fax: 601-856-9994
Mailing address:
  • Phone: 601-856-9980
  • Fax: 601-856-9994

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number10806
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number12039
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number12039
License Number StateMS

VIII. Authorized Official

Name: CAROLYN DURR
Title or Position: OFFICE MANAGER
Credential:
Phone: 601-856-9980