=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760526990
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HOLBROOK FAMILY MEDICAL PRACTICE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/19/2007
-----------------------------------------------------
Last Update Date | 04/08/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 102 OAK ST
-----------------------------------------------------
City | MENDENHALL
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39114-3650
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-847-3712
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 102 OAK ST
-----------------------------------------------------
City | MENDENHALL
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39114-3650
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-847-3712
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | CHIP D HOLBROOK
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 601-847-3712
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 14412
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------