NPIMap

Organization Active NPI

Family Medical Clinic of Cleveland, LLC

  • Family Nurse Practitioner
  • Cleveland, MS
National Provider Identifier
1346544376
Registry record updated Jan 5, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Nurse PractitionerTaxonomy code 363LF0000X
License
R855837 Issued in MS
Legal business name
FAMILY MEDICAL CLINIC OF CLEVELAND, LLC
Practice address
803 1St St
Cleveland, MS 38732-2309
Phone
(662) 843-2721
Fax
(662) 846-1728
NPI assigned
Jan 5, 2011
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 5, 2011

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

Authorized official

Name
Donald James Blackwood, M.D.
Title
President
Phone
(662) 843-2721

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Nurse PractitionerGroup: 193400000X SINGLE SPECIALTY GROUP 363LF0000X R855837 MS Primary

Addresses

Primary practice location

803 1St St
Cleveland, MS 38732-2309

Mailing address

803 1St St
Cleveland, MS 38732-2309
Phone (662) 843-2721

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20120201000920 MS Part B Supplier - Clinic/Group Practice 9335306497 Receives reassigned benefits from 7 practitioners
Practice locations: Cleveland, MS

National Provider Directory

National Provider Directory

Locations

803 1st St
Cleveland, MS 38732
Phone (601) 843-2721

Practitioners & affiliated clinicians

Practitioners 7

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

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

{
    "created_epoch": "1294185600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1294185600000",
    "number": "1346544376",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "803 1ST ST",
            "city": "CLEVELAND",
            "state": "MS",
            "postal_code": "387322309",
            "telephone_number": "662-843-2721",
            "fax_number": "662-846-1728"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "803 1ST ST",
            "city": "CLEVELAND",
            "state": "MS",
            "postal_code": "387322309",
            "telephone_number": "662-843-2721",
            "fax_number": "662-846-1728"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FAMILY MEDICAL CLINIC OF CLEVELAND, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-01-05",
        "last_updated": "2011-01-05",
        "status": "A",
        "authorized_official_last_name": "BLACKWOOD",
        "authorized_official_first_name": "DONALD",
        "authorized_official_middle_name": "JAMES",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "662-843-2721",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "363LF0000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Nurse Practitioner, Family",
            "state": "MS",
            "license": "R855837",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Cleveland, MS

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 5, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.