NPIMap

Organization Active NPI

Old Towne Medical LLC

Doing business as Old Towne Medical

  • Family Nurse Practitioner
  • Olive Branch, MS
National Provider Identifier
1013312172
Registry record updated Jul 30, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Nurse PractitionerTaxonomy code 363LF0000X
License
R644986 Issued in MS
Legal business name
OLD TOWNE MEDICAL LLC
Doing business as
Old Towne Medical
Practice address
9066 Highland St
Olive Branch, MS 38654-2307
Phone
(662) 890-7717
Fax
(662) 874-6038
NPI assigned
Oct 30, 2014
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 30, 2019

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Susan C Brame, CFNPNPI 1659336196
Title
Owner
Phone
(901) 489-6595

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Nurse PractitionerGroup: 193400000X SINGLE SPECIALTY GROUP 363LF0000X R644986 MS Primary

Addresses

Primary practice location

9066 Highland St
Olive Branch, MS 38654-2307

Mailing address

9066 Highland St
Olive Branch, MS 38654-2307
Phone (662) 890-7717

Other identifiers 1

IdentifierTypeStateIssuer
03278318MedicaidMS

Other names 1

  • Old Towne Medical Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MS

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20150219000692 MS Part B Supplier - Clinic/Group Practice 9032434881 Receives reassigned benefits from 4 practitioners
Practice locations: Olive Branch, MS

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
25D2086325Old Towne Medical LLC9066 Highland Street, Olive Branch, MS 38654Certificate of waiverOct 30, 2026

National Provider Directory

National Provider Directory

Locations

9066 Highland St
Olive Branch, MS 38654
Phone (662) 874-6164

Interoperability endpoints

  • FHIR API: https://api.platform.athenahealth.com/15038/brand/1/csg/1/fhir/r4

Practitioners & affiliated clinicians

Practitioners 4

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1414627200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1564444800000",
    "number": "1013312172",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "9066 HIGHLAND ST",
            "city": "OLIVE BRANCH",
            "state": "MS",
            "postal_code": "386542307",
            "telephone_number": "662-890-7717",
            "fax_number": "662-874-6038"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "9066 HIGHLAND ST",
            "city": "OLIVE BRANCH",
            "state": "MS",
            "postal_code": "386542307",
            "telephone_number": "662-890-7717",
            "fax_number": "662-874-6038"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "OLD TOWNE MEDICAL LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-10-30",
        "last_updated": "2019-07-30",
        "status": "A",
        "authorized_official_last_name": "BRAME",
        "authorized_official_first_name": "SUSAN",
        "authorized_official_middle_name": "C",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "901-489-6595",
        "authorized_official_credential": "CFNP"
    },
    "taxonomies": [
        {
            "code": "363LF0000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Nurse Practitioner, Family",
            "state": "MS",
            "license": "R644986",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "03278318",
            "state": "MS"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Old Towne Medical",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Old Towne Medical",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Olive Branch, MS

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 30, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.