Cassidy Bayou Medical Clinic
Organization Active NPI Family Medicine Physician · Sumner, MS
NPI 1376181990 · NPPES record last updated Apr 27, 2020
Key facts
- NPI
- 1376181990
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Family Medicine Physician 207Q00000X
- Legal business name
- CASSIDY BAYOU MEDICAL CLINIC
- Practice address
- 2372 US 49-E
Sumner, MS 38957 - Phone
- (662) 375-9310
- NPI assigned
- Dec 13, 2019
- Organization subpart
- No
Authorized official
- Name
- Sonja Bush Pennington, FNP
- Title
- Provider/Owner
- Phone
- (662) 375-2363
Practitioners 12
-
Sonja Pennington, CNP
-
Tasha Rucker, FNP
-
Charles Pringle, M.D.
-
Daniel Andrew Craven Jr., M.D.
-
Leslee Everett, PA
-
Katrina Lynn Gates, ACNP
-
Craig L Lipman, MD
-
Charles Lee Perkins II, M.D.
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 25D2052350 | Cassidy Bayou Medical Clinic | Certificate of waiver | Jan 8, 2027 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in MS
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20200204000808 | MS | Part B Supplier - Clinic/Group Practice | 4981030319 |
Receives reassigned benefits from 1 practitioner Practice locations: Sumner, MS |
National Provider Directory
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician |
207Q00000X | Yes |
Addresses
Primary practice location
2372 US 49-E
Sumner, MS 38957
Mailing address
PO Box 240
Sumner, MS 38957-0240
Phone (662) 375-9310
Other providers in Sumner, MS
- Aaron E Henry Community Health
- Court Square Rural Health Clinic
- Barbara Dew Criswell
- Greenwood Leflore Hospital
- Ewell Spencer Hudson
- Mississippi State Department of Health
All providers in Sumner, MS · Family Medicine Physician in Mississippi
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Apr 27, 2020. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.