Provider Demographics
NPI:1629237656
Name:THE CHILDREN'S MEDICAL GROUP
Entity Type:Organization
Organization Name:THE CHILDREN'S MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:HOSAN
Authorized Official - Middle Name:MENANYA
Authorized Official - Last Name:AZOMANI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-334-9915
Mailing Address - Street 1:PO BOX 1735
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38702-1735
Mailing Address - Country:US
Mailing Address - Phone:662-334-9915
Mailing Address - Fax:
Practice Address - Street 1:1421 E PEACE ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MS
Practice Address - Zip Code:39046-4938
Practice Address - Country:US
Practice Address - Phone:601-859-5955
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE CHILDREN'S MEDICAL GROUP OF GREENVILLE PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-06-05
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS18728208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02933236Medicaid
MSI23239Medicare UPIN
MS370000431Medicare PIN