Basic Information
| Provider Information | |||||||||
| NPI: | 1902949803 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEDIATRIX MEDICAL GROUP OF MISSISSIPPI, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1300 SAWGRASS CORPORATE PKWY | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SUNRISE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333232826 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002433839 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4566 S EASON BLVD | ||||||||
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| City: | TUPELO | ||||||||
| State: | MS | ||||||||
| PostalCode: | 388016540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6623774905 | ||||||||
| FaxNumber: | 6623774906 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2007 | ||||||||
| LastUpdateDate: | 08/12/2015 | ||||||||
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| AuthorizedOfficialLastName: | MASON | ||||||||
| AuthorizedOfficialFirstName: | ERIC | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8002433839 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080N0001X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 09014844 | 05 | MS | MEDICAID |