Provider Demographics
NPI:1346476322
Name:PEDIATRIC CARE CLINIC
Entity Type:Organization
Organization Name:PEDIATRIC CARE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ASHRAF
Authorized Official - Middle Name:
Authorized Official - Last Name:TABATABAII
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:985-726-2655
Mailing Address - Street 1:421 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:PICAYUNE
Mailing Address - State:MS
Mailing Address - Zip Code:39466-3160
Mailing Address - Country:US
Mailing Address - Phone:985-726-2655
Mailing Address - Fax:985-643-9808
Practice Address - Street 1:421 RIVER RD
Practice Address - Street 2:
Practice Address - City:PICAYUNE
Practice Address - State:MS
Practice Address - Zip Code:39466-3160
Practice Address - Country:US
Practice Address - Phone:985-726-2655
Practice Address - Fax:985-643-9808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-04
Last Update Date:2009-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS10074208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015403Medicaid