Provider Demographics
NPI:1285007088
Name:CHILDREN'S CLINIC OF OCEAN SPRINGS
Entity Type:Organization
Organization Name:CHILDREN'S CLINIC OF OCEAN SPRINGS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:FAIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:228-875-1184
Mailing Address - Street 1:1 MARKS RD
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-4351
Mailing Address - Country:US
Mailing Address - Phone:228-875-1184
Mailing Address - Fax:228-875-5890
Practice Address - Street 1:1 MARKS RD
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-4351
Practice Address - Country:US
Practice Address - Phone:228-875-1184
Practice Address - Fax:228-875-5890
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-03
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS09296M208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015386Medicaid