Basic Information
| Provider Information | |||||||||
| NPI: | 1588976864 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PAINE | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | CHRISTIAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | II | ||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SNIDER | ||||||||
| OtherFirstName: | CHARLES | ||||||||
| OtherMiddleName: | CHRISTIAN | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | II | ||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2500 N STATE ST | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392164500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019846562 | ||||||||
| FaxNumber: | 6018156106 | ||||||||
| Practice Location | |||||||||
| Address1: | 2500 N STATE ST | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392164500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019846562 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2010 | ||||||||
| LastUpdateDate: | 10/03/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080H0002X | 22788 | MS | Y | Allopathic & Osteopathic Physicians | Pediatrics | Hospice and Palliative Medicine | 208000000X | T-2375 | MS | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 03759341 | 05 | MS | MEDICAID |