Basic Information
| Provider Information | |||||||||
| NPI: | 1821185398 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHILDREN'S HEALTH CENTER OF COLUMBUS, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CHILDREN'S HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 114 N LEHMBERG ROAD | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6623292955 | ||||||||
| FaxNumber: | 6623701236 | ||||||||
| Practice Location | |||||||||
| Address1: | 114 N LEHMBERG ROAD | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6623292955 | ||||||||
| FaxNumber: | 6623701236 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2006 | ||||||||
| LastUpdateDate: | 06/23/2020 | ||||||||
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| AuthorizedOfficialLastName: | MCDOW | ||||||||
| AuthorizedOfficialFirstName: | SABRINA | ||||||||
| AuthorizedOfficialMiddleName: | LYNN | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6623292955 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LMSW | ||||||||
| NPICertificationDate: | 06/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 09014205 | 05 | MS | MEDICAID | 529904270 | 05 | AL | MEDICAID |