Provider Demographics
NPI:1790974111
Name:CHILDREN'S MEDICAL CENTER
Entity Type:Organization
Organization Name:CHILDREN'S MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:FAUZIA
Authorized Official - Middle Name:F
Authorized Official - Last Name:QUDDUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:228-832-0414
Mailing Address - Street 1:15465 OAK LN
Mailing Address - Street 2:SUITE 100 F
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-2663
Mailing Address - Country:US
Mailing Address - Phone:228-832-0414
Mailing Address - Fax:228-832-8227
Practice Address - Street 1:15465 OAK LN
Practice Address - Street 2:SUITE 100 F
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-2663
Practice Address - Country:US
Practice Address - Phone:228-832-0414
Practice Address - Fax:228-832-8227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-22
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS14692208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09014469Medicaid