Healthcare Provider Details

I. General information

NPI: 1174711279
Provider Name (Legal Business Name): THE CHILDREN'S MEDICAL GROUP OF GREENVILLE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2007
Last Update Date: 06/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

559 ARNOLD AVE STE A
GREENVILLE MS
38701-5323
US

IV. Provider business mailing address

PO BOX 1735
GREENVILLE MS
38702-1735
US

V. Phone/Fax

Practice location:
  • Phone: 662-334-9915
  • Fax: 662-334-9740
Mailing address:
  • Phone: 662-334-9915
  • Fax: 662-334-9740

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