# RESERVOIR FAMILY MEDICAL CLINIC, PA

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1770929713
- **Authorized official:** DR. CHARLES NAURICE CRENSHAW III MD (OWNER/PHYSICAN)
- **Authorized official phone:** (601) 992-6511

## Contact information

- **Practice address:** 1679 OLD FANNIN RD STE E, FLOWOOD, MS 39232-8101
- **Practice address phone:** (601) 992-6511
- **Practice address fax:** (601) 992-5684
- **Mailing address:** 1679 OLD FANNIN RD STE E, FLOWOOD, MS 39232-8101
- **Mailing address phone:** (601) 992-6511
- **Mailing address fax:** (601) 992-5684

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | 09099 | MS | Yes |

## Other

- **Enumeration date:** 05/17/2013
- **Last updated:** 05/29/2013