Healthcare Provider Details

I. General information

NPI: 1316180870
Provider Name (Legal Business Name): PEGAH HOSSEINI-CARROLL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2009
Last Update Date: 07/15/2022
Certification Date: 07/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 NORTH STATE STREET
JACKSON MS
39216-4500
US

IV. Provider business mailing address

185 GREEN GLADES
RIDGELAND MS
39157-8661
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-4540
  • Fax: 601-984-4548
Mailing address:
  • Phone: 601-714-6470
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number24143
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: