MEDICARE: RIVER BEND MEDICAL CLINIC, INC

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	173000000X	Legal Medicine	NO LICENCE NUMBER	MS

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	:	1568459089
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RIVER BEND MEDICAL CLINIC, INC

Provider Business Mailing Address
First Line	:	2659 LAKELAND DR
Second Line	:
City	:	FLOWOOD
State	:	MS
Zip	:	39232-9516
Country	:	US
Telephone Number	:	601-933-1199
Fax Number	:	601-933-1116

Provider Business Practice Location Address
First Line	:	2659 LAKELAND DR
Second Line	:
City	:	FLOWOOD
State	:	MS
Zip	:	39232-9516
Country	:	US
Telephone Number	:	601-933-1199
Fax Number	:	601-933-1116

Authorized Official
Title or Position	:	OWNER
Name	:	PAIGE E KEY
Credential	:	CMA XRT
Telephone Number	:	601-933-1199

Provider Enumeration Date	:	09/29/2005
Last Update Date	:	08/22/2020

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