NPIMap

Organization Active NPI

Horn Lake Family Practice Inc

  • Adolescent Medicine (Family Medicine) Physician
  • Horn Lake, MS
National Provider Identifier
1508968421
Registry record updated Jul 21, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
Adolescent Medicine (Family Medicine) PhysicianTaxonomy code 207QA0000X
License
15476 Issued in MS
Legal business name
HORN LAKE FAMILY PRACTICE INC
Practice address
3102 Goodman Rd W
Horn Lake, MS 38637-1172
Phone
(662) 342-6677
Fax
(662) 342-1213
NPI assigned
Sep 1, 2006
Last updated
Jul 21, 2015By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 21, 2015

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

Authorized official

Name
Mr. Sheetal Sharma, OTHER
Title
Office Manager
Phone
(662) 342-6677

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Adolescent Medicine (Family Medicine) Physician 207QA0000X 15476 MS Primary

Addresses

Primary practice location

3102 Goodman Rd W
Horn Lake, MS 38637-1172

Mailing address

3102 Goodman Rd W
Horn Lake, MS 38637-1172
Phone (662) 342-6677

Other identifiers 2

IdentifierTypeStateIssuer
9015003MedicaidMS
00118511MedicaidMS

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20050812000232 MS Part B Supplier - Clinic/Group Practice 9537198213 Receives reassigned benefits from 7 practitioners
Practice locations: Horn Lake, MS

National Provider Directory

National Provider Directory

Locations

3102 Goodman Rd W
Horn Lake, MS 38637
Phone (662) 342-6676

Practitioners & affiliated clinicians

Practitioners 7

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": "1157068800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1437436800000",
    "number": "1508968421",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3102 GOODMAN RD W",
            "city": "HORN LAKE",
            "state": "MS",
            "postal_code": "386371172",
            "telephone_number": "662-342-6677",
            "fax_number": "662-342-1213"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3102 GOODMAN RD W",
            "city": "HORN LAKE",
            "state": "MS",
            "postal_code": "386371172",
            "telephone_number": "662-342-6677",
            "fax_number": "662-342-1213"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "HORN LAKE FAMILY PRACTICE INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-09-01",
        "last_updated": "2015-07-21",
        "status": "A",
        "authorized_official_last_name": "SHARMA",
        "authorized_official_first_name": "SHEETAL",
        "authorized_official_title_or_position": "OFFICE MANAGER",
        "authorized_official_telephone_number": "662-342-6677",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "OTHER"
    },
    "taxonomies": [
        {
            "code": "207QA0000X",
            "taxonomy_group": "",
            "desc": "Family Medicine, Adolescent Medicine",
            "state": "MS",
            "license": "15476",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "9015003",
            "state": "MS"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00118511",
            "state": "MS"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Horn Lake, MS

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 21, 2015; 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.