Healthcare Provider Details

I. General information

NPI: 1376181990
Provider Name (Legal Business Name): CASSIDY BAYOU MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2019
Last Update Date: 04/27/2020
Certification Date: 04/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2372 US 49-E
SUMNER MS
38957
US

IV. Provider business mailing address

PO BOX 240
SUMNER MS
38957-0240
US

V. Phone/Fax

Practice location:
  • Phone: 662-375-9310
  • Fax:
Mailing address:
  • Phone: 662-375-9310
  • Fax: 662-375-9311

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: SONJA BUSH PENNINGTON
Title or Position: PROVIDER/OWNER
Credential: FNP
Phone: 662-375-2363