=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285007088
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHILDREN'S CLINIC OF OCEAN SPRINGS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/03/2015
-----------------------------------------------------
Last Update Date | 11/03/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 MARKS RD
-----------------------------------------------------
City | OCEAN SPRINGS
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39564-4351
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-875-1184
-----------------------------------------------------
Fax | 228-875-5890
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 MARKS RD
-----------------------------------------------------
City | OCEAN SPRINGS
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39564-4351
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-875-1184
-----------------------------------------------------
Fax | 228-875-5890
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR/OWNER
-----------------------------------------------------
Name | DR. GEORGE DAVID FAIN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 228-875-1184
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 09296M
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------