Internal Medicine Clinic of Clarksdale
Organization Active NPI Specialist · Clarksdale, MS
NPI 1457554479 · NPPES record last updated Jan 14, 2019
Key facts
- NPI
- 1457554479
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Specialist 174400000X
- License
- 16074 (MS)
- Legal business name
- INTERNAL MEDICINE CLINIC OF CLARKSDALE
- Practice address
- 1967 Hospital Dr
Clarksdale, MS 38614-7203 - Phone
- (662) 624-5481
- NPI assigned
- Jun 7, 2007
- Organization subpart
- No
Authorized official
- Name
- Sandra Blount
- Title
- Office Manager
- Phone
- (662) 624-5481
Practitioners 2
-
Irene Buckner, M.D.
-
Lashonda Lashay Bradley, FNP-C
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 25D0958993 | Internal Medicine Clinic | Certificate of waiver | Oct 12, 2026 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in MS
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20080703000483 | MS | Part B Supplier - Clinic/Group Practice | 9133291362 |
Receives reassigned benefits from 2 practitioners Practice locations: Clarksdale, MS |
National Provider Directory
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Specialist |
174400000X | 16074 | MS | Yes |
Addresses
Primary practice location
1967 Hospital Dr
Clarksdale, MS 38614-7203
Mailing address
1967 Hospital Dr
Clarksdale, MS 38614-7203
Other practice location 1
785 Ohio Ave Ste 2B
Clarksdale, MS 38614-6216
Phone (662) 624-5481
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 00119669 | Medicaid | MS | |
| 07922048 | Medicaid | MS |
Other providers in Clarksdale, MS
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jan 14, 2019. 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.