| Organization Name: | GRENADA LAKE MEDICAL CENTER |
| NPI Number: | 1053684548 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | DAVID G. PUTT (CEO) |
| Mailing Address: | 965 Avent Dr Ste 100a Grenada |
| State: | MS US |
| Postal Code: | 389015045 |
| Phone Number: | 6622277444 |
| Fax Number: | 6622277443 |
| NPI Enumeration Date: | 02/15/2012 |
| NPI Last Update Date: | 03/18/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 207Q00000X |
| License Number: | 21836 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MS |
| Taxonomy Type: | Allopathic & Osteopathic Physicians |
| Taxonomy Classification: | Family Medicine |
| Taxonomy Specialization: | |
| Taxonomy Definition: | Family Medicine is the medical specialty which is concerned with the total health care of the individual and the family. It is the specialty in breadth which integrates the biological, clinical, and behavioral sciences. The scope of family medicine is not limited by age, sex, organ system, or disease entity. |