NPIMap

Individual provider Active NPI

Richard Edwin Waller, M.D.

  • Family Medicine Physician
  • Marks, MS
National Provider Identifier
1821001041
Registry record updated Mar 1, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
07067 Issued in MS
Practice address
1024 Martin Luther King Drive
Marks, MS 38646-0289
Phone
(662) 326-3502
Fax
(662) 326-2555
NPI assigned
Aug 15, 2006
Last updated
Mar 1, 2017By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Mar 1, 2017

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

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X 07067 MS Primary

Addresses

Primary practice location

1024 Martin Luther King Drive
Marks, MS 38646-0289

Mailing address

PO Box 289
Marks, MS 38646-0289
Phone (662) 326-3500

Other identifiers 1

IdentifierTypeStateIssuer
00115098MedicaidMS

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MS
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20041129000760 MS Practitioner - Family PracticePractitioner - Emergency Medicine 5698745420 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Family Practice
Education
University of Mississippi School of Medicine, 1974
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Delta Medical FoundationGroup PAC ID 2163777046, 8 clinicians

Practice addresses (Care Compare)

1022 Martin Luther King Dr
Marks, MS 38646-1832
Phone (662) 326-3500

1024 Martin Luther King Dr
Marks, MS 38646-1832
Phone (662) 326-3502

PO Box
Suite 289
Marks, MS 38646-0289

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

Practice roles

OrganizationSpecialtyStatusNew patients
Delta Medical Foundation CurrentSince Apr 10, 2018 Accepting new patients
Delta Medical Foundation CurrentSince Apr 10, 2018 Accepting new patients
Tunica County Health & Rehab, LLC Past Accepting new patients
Quitman County Health & Rehab, LLC Past Accepting new patients

Locations

551 Medical Dr
Clarksdale, MS 38614
Phone (662) 624-2531

1022 Martin Luther King Dr
Marks, MS 38646
Phone (662) 326-3500

1024 Martin Luther King Dr
Marks, MS 38646
Phone (662) 326-3500

Ownership & related parties

All facility ownership & control disclosures 4

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Quitman County Health & Rehab LLCMarks, MS, CCN 255344 Skilled nursing facility Contracted Managing Employee
Adp of the SNF		 Jan 1, 2016
Jan 22, 2025
Tunica County Health & Rehab LLCTunica, MS, CCN 255334 Skilled nursing facility Adp of the SNF Jan 1, 2016
Warrington ClinicClarksdale, MS, CCN 258991 Rural health clinic Corporate Director (100%)
W-2 Managing Employee (100%)		 Apr 1, 2018
Apr 1, 2018
Family Medical CenterMarks, MS, CCN 253818 Rural health clinic Corporate Director (100%)
W-2 Managing Employee (100%)		 Apr 1, 2018
Apr 1, 2018

Owned or controlled facilities with NPI records 4

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Organizations & group practices 6

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 5

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

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

{
    "created_epoch": "1155600000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1488326400000",
    "number": "1821001041",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 289",
            "city": "MARKS",
            "state": "MS",
            "postal_code": "386460289",
            "telephone_number": "662-326-3500",
            "fax_number": "662-326-7077"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1024 MARTIN LUTHER KING DRIVE",
            "city": "MARKS",
            "state": "MS",
            "postal_code": "386460289",
            "telephone_number": "662-326-3502",
            "fax_number": "662-326-2555"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLER",
        "first_name": "RICHARD",
        "middle_name": "EDWIN",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-08-15",
        "last_updated": "2017-03-01",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "MS",
            "license": "07067",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00115098",
            "state": "MS"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Marks, MS

Sources for this page

Verify at the official NPI Registry.