Provider Demographics
NPI:1245872514
Name:P&S PRIMARY CARE, PLLC
Entity type:Organization
Organization Name:P&S PRIMARY CARE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:BODEN
Authorized Official - Suffix:
Authorized Official - Credentials:CMPE
Authorized Official - Phone:662-256-9331
Mailing Address - Street 1:900 EARL FRYE BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:AMORY
Mailing Address - State:MS
Mailing Address - Zip Code:38821-5507
Mailing Address - Country:US
Mailing Address - Phone:662-256-9331
Mailing Address - Fax:
Practice Address - Street 1:900 EARL FRYE BLVD STE A
Practice Address - Street 2:
Practice Address - City:AMORY
Practice Address - State:MS
Practice Address - Zip Code:38821-5507
Practice Address - Country:US
Practice Address - Phone:662-256-9331
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:P & S CLINIC OB-GYN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-10-08
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty