| Organization Name: | GOUGH'S FAMILY AND PEDIATRIC CLINIC |
| NPI Number: | 1528306222 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | WALTER GOUGH (OWNER/PHYSICIAN) |
| Mailing Address: | 189 N Main St Drew |
| State: | MS US |
| Postal Code: | 387373146 |
| Phone Number: | 6627456638 |
| Fax Number: | 6627458480 |
| NPI Enumeration Date: | 01/30/2013 |
| NPI Last Update Date: | 01/30/2013 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QP2300X |
| License Number: | 06639 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MS |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Primary Care |
| Taxonomy Definition: | |