Provider Demographics
NPI:1538187414
Name:LOUISVILLE MEDICAL ASSOCIATES PA
Entity type:Organization
Organization Name:LOUISVILLE MEDICAL ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-773-7500
Mailing Address - Street 1:PO BOX 190
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39339-0190
Mailing Address - Country:US
Mailing Address - Phone:662-773-7500
Mailing Address - Fax:662-779-5006
Practice Address - Street 1:564 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:MS
Practice Address - Zip Code:39339-2742
Practice Address - Country:US
Practice Address - Phone:662-773-7500
Practice Address - Fax:662-779-5006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2013-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09014428Medicaid
258904Medicare Oscar/Certification
MS258904Medicare ID - Type UnspecifiedRIVERBEND GROUP