Basic Information
| Provider Information | |||||||||
| NPI: | 1619188026 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRIFFIN | ||||||||
| FirstName: | KAISHA | ||||||||
| MiddleName: | RENADA | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 105 MASON COVE | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39110 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 350 W WOODROW WILSON AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392137681 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017095130 | ||||||||
| FaxNumber: | 6017095151 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2007 | ||||||||
| LastUpdateDate: | 06/25/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208000000X | T-1990 | MS | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 21093 | MS | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.