Provider Demographics
NPI:1891150629
Name:PICAYUNE PEDIATRICS LLC
Entity Type:Organization
Organization Name:PICAYUNE PEDIATRICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:JO
Authorized Official - Last Name:ALEXANDER
Authorized Official - Suffix:
Authorized Official - Credentials:CPNP
Authorized Official - Phone:601-590-1045
Mailing Address - Street 1:1704 W FOURTH AVE
Mailing Address - Street 2:
Mailing Address - City:PICAYUNE
Mailing Address - State:MS
Mailing Address - Zip Code:39466-3112
Mailing Address - Country:US
Mailing Address - Phone:601-590-1045
Mailing Address - Fax:
Practice Address - Street 1:200 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:CARRIERE
Practice Address - State:MS
Practice Address - Zip Code:39426-9037
Practice Address - Country:US
Practice Address - Phone:601-590-1045
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-21
Last Update Date:2015-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR687693305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization