Provider Demographics
NPI:1942606256
Name:IVANCIC PEDIATRIC CLINIC PA
Entity Type:Organization
Organization Name:IVANCIC PEDIATRIC CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MITZI
Authorized Official - Middle Name:
Authorized Official - Last Name:PARSONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-840-6026
Mailing Address - Street 1:499 GLOSTER CREEK VLG
Mailing Address - Street 2:SUITE H-3
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-4600
Mailing Address - Country:US
Mailing Address - Phone:662-840-6026
Mailing Address - Fax:662-840-6030
Practice Address - Street 1:499 GLOSTER CREEK VLG
Practice Address - Street 2:SUITE H-3
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-4600
Practice Address - Country:US
Practice Address - Phone:662-840-6026
Practice Address - Fax:662-840-6030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-13
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care