Individual Professional Information |
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NPI
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1124048277
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Unique healthcare provider (clinician) ID assigned by NPPES
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PECOS UID
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7618060575
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Unique individual clinician ID assigned by PECOS
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Professional Enrollment ID
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I20141217002480
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Unique ID for the individual professional enrollment that is the source for the data in the observation
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Provider Last Name
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FORD
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Individual professional last name
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Provider First Name
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REAGAN
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Individual professional first name
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Provider Middle Name
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L
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Individual professional middle name
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Provider Name Suffix Text
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SR.
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The name suffix of the provider if the provider is an individual. The name suffix is a ''generation-related'' suffix, such as Jr., Sr., II, III, IV, or V.
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Provider Gender
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M
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The provider's gender if the provider is a person.
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Practice Information |
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Organization Legal Name
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JTM ENTERPRISES, PLLC
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Legal name of the Group Practice that the individual professional works with- will be blank if the address is not linked to a Group Practice
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Group Practice PAC ID
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7911256656
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Unique Group Practice ID assigned by PECOS to the Group Practice that the individual professional works with- will be blank if the address is not linked to a Group Practice
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Number of Group Practice members
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2
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Total number of individual professionals affiliated with the Group Practice based on Group Practice PAC ID
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Line 1 Street Address
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706 HWY 12 W F
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Group Practice or individual's line 1 address
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Line 2 Street Address
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FORD VISION CLINIC
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Group Practice or individual's line 2 address
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City
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STARKVILLE
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Group Practice or individual's city
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State
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MS
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Group Practice or individual's state
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Zip Code
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397593573
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Group Practice or individual's zip code (9 digits when available)
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Phone Number
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6623230571
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Phone number is listed only when there is a single phone number available for the practice location address
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