Provider Demographics
NPI:1609037381
Name:CHILDREN'S CLINIC
Entity Type:Organization
Organization Name:CHILDREN'S CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:RANGSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SUVAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:573-686-2585
Mailing Address - Street 1:2500 LUCY LEE PKWY
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-2436
Mailing Address - Country:US
Mailing Address - Phone:573-686-2585
Mailing Address - Fax:
Practice Address - Street 1:2500 LUCY LEE PKWY
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-2436
Practice Address - Country:US
Practice Address - Phone:573-686-2585
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-24
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR131252002OtherARKANSAS GROUP MEDICAID