Provider Demographics
NPI:1538675798
Name:THE PEDZ CLINIC
Entity Type:Organization
Organization Name:THE PEDZ CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:KELLI
Authorized Official - Middle Name:
Authorized Official - Last Name:FEWELL
Authorized Official - Suffix:
Authorized Official - Credentials:PNP-PC
Authorized Official - Phone:601-439-7221
Mailing Address - Street 1:610 3RD ST SW
Mailing Address - Street 2:
Mailing Address - City:MAGEE
Mailing Address - State:MS
Mailing Address - Zip Code:39111-3994
Mailing Address - Country:US
Mailing Address - Phone:601-439-7221
Mailing Address - Fax:601-439-7193
Practice Address - Street 1:610 3RD ST SW
Practice Address - Street 2:
Practice Address - City:MAGEE
Practice Address - State:MS
Practice Address - Zip Code:39111-3994
Practice Address - Country:US
Practice Address - Phone:601-439-7221
Practice Address - Fax:601-439-7193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-22
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR879688208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04038362Medicaid
MS1154684363Medicaid