| Grenada Specialty Clinic - Terry Pummer | |
|
965 Avent Dr Ste 100a Grenada MS 38901-5045 | |
| (662) 227-7444 | |
| (662) 227-7443 |
| Full Name | Grenada Specialty Clinic - Terry Pummer |
|---|---|
| Speciality | Family Medicine |
| Location | 965 Avent Dr Ste 100a, Grenada, Mississippi |
| Authorized Official Name and Position | David G. Putt (CEO) |
| Authorized Official Contact | 6622277000 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Grenada Specialty Clinic - Terry Pummer 965 Avent Dr Ste 100a Grenada MS 38901-5045 Ph: (662) 227-7444 | Grenada Specialty Clinic - Terry Pummer 965 Avent Dr Ste 100a Grenada MS 38901-5045 Ph: (662) 227-7444 |
| NPI Number | 1053684548 |
|---|---|
| Provider Enumeration Date | 02/15/2012 |
| Last Update Date | 03/18/2014 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1053684548 | NPI | - | NPPES |
| 11516802 | Other | MS | CAQH |
| 00059747 | Medicaid | MS |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207Q00000X | Family Medicine | 21836 (Mississippi) | Primary |
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