Active NPI
Grenada Lake Medical Center
- Family Medicine Physician
- Grenada, MS
National Provider Identifier
1053684548
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Family Medicine Physician
- License
- 21836
- Legal business name
- GRENADA LAKE MEDICAL CENTER
- Practice address
- 965 Avent Dr Ste 100a
Grenada, MS 38901-5045 - Phone
- (662) 227-7444
- Fax
- (662) 227-7443
- NPI assigned
- Feb 15, 2012
- Organization subpart
- Yes
- Parent organization
- GRENADA LAKE MEDICAL CENTER
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Authorized official
- Name
- Mr. David G. Putt, FACHE
- Title
- Ceo
- Phone
- (662) 227-7000
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | 21836 | MS | Primary |
Addresses
Primary practice location
965 Avent Dr Ste 100a
Grenada, MS 38901-5045
Mailing address
965 Avent Dr Ste 100a
Grenada, MS 38901-5045
Phone (662) 227-7444
Other identifiers 2
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 11516802 | Other | MS | CAQH |
| 00059747 | Medicaid | MS |
Other names 1
- Grenada Specialty Clinic - Terry Pummer
National Provider Directory
National Provider Directory- Part of
- Grenada Lake Medical Ce
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1329264000000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1395100800000",
"number": "1053684548",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "965 AVENT DR STE 100A",
"city": "GRENADA",
"state": "MS",
"postal_code": "389015045",
"telephone_number": "662-227-7444",
"fax_number": "662-227-7443"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "965 AVENT DR STE 100A",
"city": "GRENADA",
"state": "MS",
"postal_code": "389015045",
"telephone_number": "662-227-7444",
"fax_number": "662-227-7443"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "GRENADA LAKE MEDICAL CENTER",
"organizational_subpart": "YES",
"parent_organization_legal_business_name": "GRENADA LAKE MEDICAL CENTER",
"enumeration_date": "2012-02-15",
"last_updated": "2014-03-18",
"status": "A",
"authorized_official_last_name": "PUTT",
"authorized_official_first_name": "DAVID",
"authorized_official_middle_name": "G.",
"authorized_official_title_or_position": "CEO",
"authorized_official_telephone_number": "662-227-7000",
"authorized_official_name_prefix": "Mr.",
"authorized_official_credential": "FACHE"
},
"taxonomies": [
{
"code": "207Q00000X",
"taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
"desc": "Family Medicine",
"state": "MS",
"license": "21836",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "CAQH",
"identifier": "11516802",
"state": "MS"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "00059747",
"state": "MS"
}
],
"endpoints": [],
"other_names": [
{
"organization_name": "Grenada Specialty Clinic - Terry Pummer",
"code": "3",
"type": "Doing Business As"
}
]
}Other providers in Grenada, MS
- Grenada Family Chiropractic Inc
- Grenada Family Medicine Clinic
- Grenada Hematology Oncology LLC
- Grenada Lake Inpatient Medicine Associates
- Grenada Lake Medical Center
- Grenada Lake Medical Center
- Grenada Lake Medical Center
- Grenada Lake Medical Center
- Grenada Lake Medical Center
- Grenada Lake Medical Center
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 18, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.