Provider Demographics
NPI:1750316907
Name:CHILDRENS CLINIC OF PASCAGOULA PLLC
Entity Type:Organization
Organization Name:CHILDRENS CLINIC OF PASCAGOULA PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ALTAF
Authorized Official - Middle Name:
Authorized Official - Last Name:JAMAL
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:228-762-8712
Mailing Address - Street 1:4105 HOSPITAL ST
Mailing Address - Street 2:STE 103
Mailing Address - City:PASCAGOULA
Mailing Address - State:MS
Mailing Address - Zip Code:39581-5312
Mailing Address - Country:US
Mailing Address - Phone:228-762-8712
Mailing Address - Fax:228-762-2261
Practice Address - Street 1:4105 HOSPITAL ST
Practice Address - Street 2:STE 103
Practice Address - City:PASCAGOULA
Practice Address - State:MS
Practice Address - Zip Code:39581-5312
Practice Address - Country:US
Practice Address - Phone:228-762-8712
Practice Address - Fax:228-762-2261
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015404Medicaid