OLD TOWNE MEDICAL LLC NPI 1013312172

NPI Information

NPI: 1013312172
Provider Name: OLD TOWNE MEDICAL LLC

Doing Business As: OLD TOWNE MEDICAL

Classification: Nurse Practitioner - 363LF0000X
Entity Type: Organization

Specialization: Family

CLIA Number: 25D2086325

Address:
9066 HIGHLAND ST
OLIVE BRANCH, MS
ZIP 38654
Phone: (662) 890-7717
Get Directions

OLD TOWNE MEDICAL LLC is a family nurse practitioner in Olive Branch, MS. OLD TOWNE MEDICAL LLC NPI is 1013312172. The provider is registered as an organization entity type and is a single specialty group.
The provider Is Doing Business As Old Towne Medical.

The provider's business location address is:

9066 HIGHLAND ST
OLIVE BRANCH, MS
ZIP 38654-307
Phone: (662) 890-7717
Fax: (662) 874-6038

The provider's authorized official is Susan C Brame .
The authorized official title is Owner and has the following contact phone number (901) 489-6595.

The CLIA number assigned to this NPI record is 25D2086325 - practitioner other with a certificate type of Certificate of Waiver.

The enumeration date for this NPI number is 10/30/2014 and was last updated on 7/30/2019.

Taxonomy Codes

The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:

No.	Taxonomy Code	Taxonomy Clasification	Taxonomy Specialization	License Number	License State	Primary
1	363LF0000X	Nurse Practitioner	Family	R644986	MISSISSIPPI	Yes

Other Identifiers

The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.

No.	Other Provider Identifier	Other Provider Identifier Type	Other Provider Identifier State	Other Provider Identifier Issuer
1	03278318	MEDICAID	MISSISSIPPI

What is NPI?

NPI stands for National Provider Identifier. The NPI is a 10-digit identification number that is completely unique. The NPI number by itself does not contain any identifiable information such as a provider’s speciality or location. The NPI is assigned to individuals or organizacions for their lifespan and it is independent of key provider information type updates like a change of practices, location or speciality.

This page was last updated on: 5/5/2024

NPI Synchronization or Removal

All materials and services on this site are provided on an "as is" and "as available" basis without warranty of any kind. The NPI record is maintained by the National Plan & Provider Enumeration System (NPPES) and anyone may request this information and other NPPES health care provider data from HHS under The Freedom of Information Act (FOIA), Title 5 of the United States Code, section 552. To update the NPI records please contact the NPPES.

« Previous NPI

Next NPI »