Healthcare Provider Details

I. General information

NPI: 1902121866
Provider Name (Legal Business Name): MAGEE BENEVOLENT ASSN DBA PEDIATRIC CLINIC OF MAGEE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2010
Last Update Date: 04/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 3RD AVE SE
MAGEE MS
39111-3665
US

IV. Provider business mailing address

300 3RD AVE SE
MAGEE MS
39111-3665
US

V. Phone/Fax

Practice location:
  • Phone: 601-849-7215
  • Fax: 601-849-7221
Mailing address:
  • Phone: 601-849-7215
  • Fax: 601-849-7221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: NANCY R EATMON
Title or Position: PRACTICE MANAGER
Credential:
Phone: 601-849-7215