Healthcare Provider Details

I. General information

NPI: 1245691161
Provider Name (Legal Business Name): ZACKARY ATOM CHARLES KNOTT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2016
Last Update Date: 08/21/2020
Certification Date: 08/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST
JACKSON MS
39216-4500
US

IV. Provider business mailing address

2500 N. STATE STREET CBO - SUITE 4200
JACKSON MS
39216
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-5532
  • Fax: 601-984-6665
Mailing address:
  • Phone: 601-815-2005
  • Fax: 601-815-0434

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number25610
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25610
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25610
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: