MEDICARE: FAMILY MEDICAL CLINIC OF CRYSTAL SPRINGS PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1205915998
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY MEDICAL CLINIC OF CRYSTAL SPRINGS PLLC

Provider Business Mailing Address
First Line	:	104 W RAILROAD AVE S
Second Line	:
City	:	CRYSTAL SPRINGS
State	:	MS
Zip	:	39059-2111
Country	:	US
Telephone Number	:	601-892-3063
Fax Number	:	601-892-3570

Provider Business Practice Location Address
First Line	:	104 W RAILROAD AVE S
Second Line	:
City	:	CRYSTAL SPRINGS
State	:	MS
Zip	:	39059-2111
Country	:	US
Telephone Number	:	601-892-3063
Fax Number	:	601-892-3570

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JAMES W ERVIN
Credential	:	M.D.
Telephone Number	:	601-892-3063

Provider Enumeration Date	:	11/03/2006
Last Update Date	:	11/18/2025

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