Healthcare Provider Details

I. General information

NPI: 1114118940
Provider Name (Legal Business Name): CENTRAL MS PEDIATRIC ENDOCRINOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2007
Last Update Date: 08/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1860 CHADWICK DR SUITE 206
JACKSON MS
39204-3463
US

IV. Provider business mailing address

1860 CHADWICK DR SUITE 206
JACKSON MS
39204-3463
US

V. Phone/Fax

Practice location:
  • Phone: 601-376-1517
  • Fax: 601-376-1546
Mailing address:
  • Phone: 601-376-1517
  • Fax: 601-376-1546

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State

VIII. Authorized Official

Name: BRAD SINCLAIR
Title or Position: REGIONAL MANAGER
Credential:
Phone: 601-936-3102