Healthcare Provider Details

I. General information

NPI: 1578719571
Provider Name (Legal Business Name): BASTIAN CENTER OF PEDIATRIC ENDOCRINOLOGY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2008
Last Update Date: 08/11/2008
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: 601-376-1545
  • Fax:
Mailing address:
  • Phone: 601-376-1545
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number19260
License Number StateMS

VIII. Authorized Official

Name: WILLIAM BASTIAN
Title or Position: PROVIDER/OWNER
Credential: M.D.
Phone: 601-376-1545