Provider Demographics
NPI:1336369156
Name:SENATOBIA CHILDRENS CLINIC PC
Entity Type:Organization
Organization Name:SENATOBIA CHILDRENS CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DESH
Authorized Official - Middle Name:DEEPAK
Authorized Official - Last Name:SIDHU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-562-4418
Mailing Address - Street 1:104 COURT ST
Mailing Address - Street 2:
Mailing Address - City:SENATOBIA
Mailing Address - State:MS
Mailing Address - Zip Code:38668-2606
Mailing Address - Country:US
Mailing Address - Phone:662-562-4418
Mailing Address - Fax:662-562-9024
Practice Address - Street 1:104 COURT ST
Practice Address - Street 2:
Practice Address - City:SENATOBIA
Practice Address - State:MS
Practice Address - Zip Code:38668-2606
Practice Address - Country:US
Practice Address - Phone:662-562-4418
Practice Address - Fax:662-562-9024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09014227Medicaid