Provider Demographics
NPI:1497834030
Name:CHILDRENS CLINIC OF CLARKSDALE PA
Entity Type:Organization
Organization Name:CHILDRENS CLINIC OF CLARKSDALE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROLE
Authorized Official - Middle Name:L
Authorized Official - Last Name:MANGREM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-627-4131
Mailing Address - Street 1:PO BOX 1447
Mailing Address - Street 2:
Mailing Address - City:CLARKSDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38614
Mailing Address - Country:US
Mailing Address - Phone:662-627-4131
Mailing Address - Fax:662-627-2702
Practice Address - Street 1:2245 N STATE STREET
Practice Address - Street 2:
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614
Practice Address - Country:US
Practice Address - Phone:662-627-4131
Practice Address - Fax:662-627-2702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS07191208000000X
MS07070208000000X
MSR861078208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09013997Medicaid