| Ellisville Pediatric Clinic | |
|
1203 Ave B Suite 200 Ellisville MS 39437 | |
| (601) 477-3550 | |
| (601) 477-2236 |
| Full Name | Ellisville Pediatric Clinic |
|---|---|
| Speciality | Clinic/Center |
| Location | 1203 Ave B, Ellisville, Mississippi |
| Authorized Official Name and Position | Monica Morrow (DIRECTOR CLINIC SUPPORT) |
| Authorized Official Contact | 6013996167 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Ellisville Pediatric Clinic Po Box 247 Laurel MS 39441-0247 Ph: (601) 425-7550 | Ellisville Pediatric Clinic 1203 Ave B Suite 200 Ellisville MS 39437 Ph: (601) 477-3550 |
| NPI Number | 1427098003 |
|---|---|
| Provider Enumeration Date | 06/08/2006 |
| Last Update Date | 07/25/2018 |
| Medicare PECOS PAC ID | 4385876655 |
|---|---|
| Medicare Enrollment ID | O20180126000848 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1427098003 | NPI | - | NPPES |
| 09014135 | Medicaid | MS |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QR1300X | Clinic/center - Rural Health | 253437 (Mississippi) | Primary |
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