Richard Edwin Waller, M.D.
Individual provider Active NPI Family Medicine Physician · Marks, MS
NPI 1821001041 · NPPES record last updated Mar 1, 2017
Key facts
- NPI
- 1821001041
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Family Medicine Physician 207Q00000X
- License
- 07067 (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
- Sex
- Male
- Sole proprietor
- No
Organizations & group practices 4
Hospital & facility affiliations 5
Owned or controlled facilities with NPI records 4
Medicare Care Compare profile
- 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 Foundation
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
- Accentcare Home Health of Greenwood
- Baptist Memorial Hospital North Ms
- Baptist Memorial Hospital Desoto
- Tunica County Health & Rehab, LLC
- Quitman County Health & Rehab LLC
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in MS
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: Yes
All facility ownership & control disclosures 4
| Facility | Type | Role | Since |
|---|---|---|---|
| Quitman County Health & Rehab LLC |
Skilled nursing facility | Contracted Managing Employee Adp of the SNF |
Jan 1, 2016 Jan 22, 2025 |
| Tunica County Health & Rehab LLC |
Skilled nursing facility | Adp of the SNF | Jan 1, 2016 |
| Warrington Clinic |
Rural health clinic | Corporate Director (100%) W-2 Managing Employee (100%) |
Apr 1, 2018 Apr 1, 2018 |
| Family Medical Center |
Rural health clinic | Corporate Director (100%) W-2 Managing Employee (100%) |
Apr 1, 2018 Apr 1, 2018 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20041129000760 | MS | Practitioner - Family Practice |
5698745420 | Reassigns benefits to 1 organization |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 07067 | MS | MD | Family Medicine Physician |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Delta Medical Foundation | Current |
Accepting new patients | |
| Delta Medical Foundation | Current |
Accepting new patients | |
| Quitman County Health & Rehab, LLC | Past | Accepting new patients | |
| Tunica County Health & Rehab, LLC | Past | Accepting new patients |
Locations
551 Medical Dr
Clarksdale, MS 38614
Phone (662) 624-2531
1024 Martin Luther King Dr
Marks, MS 38646
Phone (662) 326-3500
1022 Martin Luther King Dr
Marks, MS 38646
Phone (662) 326-3500
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | 07067 | MS | Yes |
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
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 00115098 | Medicaid | MS |
Other providers in Marks, MS
- The W: Therapeutic Group, LLC
- Ashley Megan Thompson
- Patsy Ann Thompson
- Joseph Tubbs
- Loretta Walker
- Warrington Clinic
- Warrington Clinic, P.a.
- Jennifer Whitaker
- Patricia Wright Hankins
All providers in Marks, 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 Mar 1, 2017. 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.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Order and Referring (CMS).
- 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.