Basic Information
| Provider Information | |||||||||
| NPI: | 1093972929 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HADDAD | ||||||||
| FirstName: | ELLEN | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KRIMITSOS | ||||||||
| OtherFirstName: | ELLEN | ||||||||
| OtherMiddleName: | G | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DO | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 300 RAWLS DR | ||||||||
| Address2: | SUITE 1000 | ||||||||
| City: | MCCOMB | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396482877 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012504210 | ||||||||
| FaxNumber: | 6012504212 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 RAWLS DR | ||||||||
| Address2: | SUITE 1000 | ||||||||
| City: | MCCOMB | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396482877 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012504210 | ||||||||
| FaxNumber: | 6012504212 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2008 | ||||||||
| LastUpdateDate: | 07/15/2013 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | T-2438 | MS | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2084N0400X | 22039 | MS | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
No ID Information.