Provider Demographics
NPI:1659523876
Name:PEDIATRIC CENTER OF JACKSON
Entity Type:Organization
Organization Name:PEDIATRIC CENTER OF JACKSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SOUHA
Authorized Official - Middle Name:S
Authorized Official - Last Name:HAKIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:517-783-1779
Mailing Address - Street 1:1418 E MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49202-3518
Mailing Address - Country:US
Mailing Address - Phone:517-783-1779
Mailing Address - Fax:517-783-1899
Practice Address - Street 1:1418 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-3518
Practice Address - Country:US
Practice Address - Phone:517-783-1779
Practice Address - Fax:517-783-1899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-21
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISS068721208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104499710Medicaid