Provider Demographics
NPI:1952496101
Name:COLUMBUS CHILDRENS CLINIC
Entity Type:Organization
Organization Name:COLUMBUS CHILDRENS CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:SYKES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-327-8410
Mailing Address - Street 1:2402 5TH ST N
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39705-2000
Mailing Address - Country:US
Mailing Address - Phone:662-327-8410
Mailing Address - Fax:662-327-9749
Practice Address - Street 1:2402 5TH ST N
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705-2000
Practice Address - Country:US
Practice Address - Phone:662-327-8410
Practice Address - Fax:662-327-9749
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13916208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015096Medicaid