Basic Information
| Provider Information | |||||||||
| NPI: | 1871514190 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ACORN PEDIATRICS PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1055 | ||||||||
| Address2: | |||||||||
| City: | PICAYUNE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394661055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017985558 | ||||||||
| FaxNumber: | 6017989915 | ||||||||
| Practice Location | |||||||||
| Address1: | 1016 SIXTH AVE STE A | ||||||||
| Address2: | |||||||||
| City: | PICAYUNE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394663804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017985558 | ||||||||
| FaxNumber: | 6017989915 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 04/10/2013 | ||||||||
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| AuthorizedOfficialLastName: | BALOGUN | ||||||||
| AuthorizedOfficialFirstName: | ABIODUN | ||||||||
| AuthorizedOfficialMiddleName: | F. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6017989987 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 19061 | MS | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1994596 | 05 | LA | MEDICAID | 08437778 | 05 | MS | MEDICAID |