Healthcare Provider Details

I. General information

NPI: 1366042236
Provider Name (Legal Business Name): MISSISSIPPI CHILDRENS HEART CLINIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2020
Last Update Date: 10/29/2020
Certification Date: 10/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1190 N STATE ST STE 200
JACKSON MS
39202-2413
US

IV. Provider business mailing address

PO BOX 22646
JACKSON MS
39225-2646
US

V. Phone/Fax

Practice location:
  • Phone: 601-965-6100
  • Fax:
Mailing address:
  • Phone: 601-944-1717
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number
License Number State

VIII. Authorized Official

Name: STEPHANIE PURVIS
Title or Position: OFFICE MANAGER
Credential: OFFICE MANAGER
Phone: 601-965-6100