Healthcare Provider Details

I. General information

NPI: 1285007088
Provider Name (Legal Business Name): CHILDREN'S CLINIC OF OCEAN SPRINGS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2015
Last Update Date: 11/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MARKS RD
OCEAN SPRINGS MS
39564-4351
US

IV. Provider business mailing address

1 MARKS RD
OCEAN SPRINGS MS
39564-4351
US

V. Phone/Fax

Practice location:
  • Phone: 228-875-1184
  • Fax: 228-875-5890
Mailing address:
  • Phone: 228-875-1184
  • Fax: 228-875-5890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number09296M
License Number StateMS

VIII. Authorized Official

Name: DR. GEORGE DAVID FAIN
Title or Position: DOCTOR/OWNER
Credential: M.D.
Phone: 228-875-1184