Healthcare Provider Details

I. General information

NPI: 1588700603
Provider Name (Legal Business Name): CHILDREN'S MEDICAL GROUP, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1867 CRANE RIDGE DR STE 101B
JACKSON MS
39216-4956
US

IV. Provider business mailing address

1867 CRANE RIDGE DR STE 101B
JACKSON MS
39216-4956
US

V. Phone/Fax

Practice location:
  • Phone: 601-362-8776
  • Fax: 601-354-8786
Mailing address:
  • Phone: 601-362-8776
  • Fax: 601-354-8786

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. WILLIAM H. SMITH JR.
Title or Position: PRESIDENT
Credential: M.D.
Phone: 601-856-5105