Provider Demographics
NPI:1689861478
Name:WADSWORTH CLINIC, P. A.
Entity type:Organization
Organization Name:WADSWORTH CLINIC, P. A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:M
Authorized Official - Last Name:WADSWORTH
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:662-429-5231
Mailing Address - Street 1:2240 HIGHWAY 51 S
Mailing Address - Street 2:
Mailing Address - City:HERNANDO
Mailing Address - State:MS
Mailing Address - Zip Code:38632-1737
Mailing Address - Country:US
Mailing Address - Phone:662-429-5231
Mailing Address - Fax:662-429-4922
Practice Address - Street 1:2240 HIGHWAY 51 S
Practice Address - Street 2:
Practice Address - City:HERNANDO
Practice Address - State:MS
Practice Address - Zip Code:38632-1737
Practice Address - Country:US
Practice Address - Phone:662-429-5231
Practice Address - Fax:662-429-4922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-26
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1194750653OtherUPIN