Healthcare Provider Details

I. General information

NPI: 1497705446
Provider Name (Legal Business Name): COCKRELL FAMILY MEDICAL CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 NORFLEET DR
SENATOBIA MS
38668-2220
US

IV. Provider business mailing address

120 NORFLEET DR
SENATOBIA MS
38668-2220
US

V. Phone/Fax

Practice location:
  • Phone: 662-301-1128
  • Fax: 662-301-4430
Mailing address:
  • Phone: 662-301-1128
  • Fax: 662-301-4430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberM17248
License Number StateMS

VIII. Authorized Official

Name: JESSIE MICHAEL COCKRELL
Title or Position: PRESIDENT
Credential: MD
Phone: 662-301-1128