Provider Demographics
NPI:1275597544
Name:CHILDREN'S CLINIC OF TUPELO, PA
Entity Type:Organization
Organization Name:CHILDREN'S CLINIC OF TUPELO, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:SHEFFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-842-6088
Mailing Address - Street 1:458 E PRESIDENT AVE
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-5515
Mailing Address - Country:US
Mailing Address - Phone:662-842-6088
Mailing Address - Fax:662-842-3229
Practice Address - Street 1:458 E PRESIDENT AVE
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-5515
Practice Address - Country:US
Practice Address - Phone:662-842-6088
Practice Address - Fax:662-842-3229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02782773Medicaid