Healthcare Provider Details

I. General information

NPI: 1538675798
Provider Name (Legal Business Name): THE PEDZ CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2017
Last Update Date: 08/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 3RD ST SW
MAGEE MS
39111-3994
US

IV. Provider business mailing address

610 3RD ST SW
MAGEE MS
39111-3994
US

V. Phone/Fax

Practice location:
  • Phone: 601-439-7221
  • Fax: 601-439-7193
Mailing address:
  • Phone: 601-439-7221
  • Fax: 601-439-7193

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberR879688
License Number StateMS

VIII. Authorized Official

Name: KELLI FEWELL
Title or Position: PEDIATRIC NURSE PRACTITIONER
Credential: PNP-PC
Phone: 601-439-7221