Healthcare Provider Details

I. General information

NPI: 1629237656
Provider Name (Legal Business Name): THE CHILDREN'S MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2008
Last Update Date: 06/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1421 E PEACE ST
CANTON MS
39046-4938
US

IV. Provider business mailing address

PO BOX 1735
GREENVILLE MS
38702-1735
US

V. Phone/Fax

Practice location:
  • Phone: 601-859-5955
  • Fax:
Mailing address:
  • Phone: 662-334-9915
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number18728
License Number StateMS

VIII. Authorized Official

Name: DR. HOSAN MENANYA AZOMANI
Title or Position: MANAGER
Credential: MD
Phone: 662-334-9915