Basic Information
| Provider Information | |||||||||
| NPI: | 1366042236 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MISSISSIPPI CHILDRENS HEART CLINIC PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 22646 | ||||||||
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| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392252646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019441717 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1190 N STATE ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392022413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019656100 | ||||||||
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| ProviderEnumerationDate: | 10/29/2020 | ||||||||
| LastUpdateDate: | 10/29/2020 | ||||||||
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| AuthorizedOfficialLastName: | PURVIS | ||||||||
| AuthorizedOfficialFirstName: | STEPHANIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6019656100 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | OFFICE MANAGER | ||||||||
| NPICertificationDate: | 10/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology |
No ID Information.