Provider Demographics
NPI:1902997059
Name:FAMILY MED 101, INC
Entity Type:Organization
Organization Name:FAMILY MED 101, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:FELESHA
Authorized Official - Middle Name:D
Authorized Official - Last Name:PERRIGO
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:662-720-4919
Mailing Address - Street 1:PO BOX 60
Mailing Address - Street 2:
Mailing Address - City:BOONEVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38829-0060
Mailing Address - Country:US
Mailing Address - Phone:662-720-4919
Mailing Address - Fax:662-720-4980
Practice Address - Street 1:101 MIMOSA ST
Practice Address - Street 2:
Practice Address - City:BOONEVILLE
Practice Address - State:MS
Practice Address - Zip Code:38829-2911
Practice Address - Country:US
Practice Address - Phone:662-720-4919
Practice Address - Fax:662-720-4980
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2017-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR763457261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSC03615Medicare PIN
MS258994Medicare Oscar/Certification
MS258994Medicare Oscar/Certification