Provider Demographics
NPI:1770929713
Name:RESERVOIR FAMILY MEDICAL CLINIC, PA
Entity type:Organization
Organization Name:RESERVOIR FAMILY MEDICAL CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAN
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:NAURICE
Authorized Official - Last Name:CRENSHAW
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:601-992-6511
Mailing Address - Street 1:1679 OLD FANNIN RD STE E
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-8101
Mailing Address - Country:US
Mailing Address - Phone:601-992-6511
Mailing Address - Fax:601-992-5684
Practice Address - Street 1:1679 OLD FANNIN RD STE E
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-8101
Practice Address - Country:US
Practice Address - Phone:601-992-6511
Practice Address - Fax:601-992-5684
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-17
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS09099207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSB30608Medicare UPIN