MEDICARE: OLIVE BRANCH PRIMARY CARE, 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	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1871918789
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OLIVE BRANCH PRIMARY CARE, PLLC

Provider Business Mailing Address
First Line	:	1405 NOTTINGHAM DR
Second Line	:
City	:	SOUTHAVEN
State	:	MS
Zip	:	38671-9474
Country	:	US
Telephone Number	:	662-349-0406
Fax Number	:	662-349-0406

Provider Business Practice Location Address
First Line	:	7163 GOODMAN RD
Second Line	:
City	:	OLIVE BRANCH
State	:	MS
Zip	:	38654-1904
Country	:	US
Telephone Number	:	662-895-3700
Fax Number	:	662-895-4886

Authorized Official
Title or Position	:	OFFICE ADMINISTRATOR
Name	:	KAREN M TATE
Credential	:
Telephone Number	:	662-895-3700

Provider Enumeration Date	:	02/28/2014
Last Update Date	:	02/28/2014

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