Organization
CHILDRENS CLINIC OF CLARKSDALE PA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MS. CAROLE L MANGREM MD (PARTNER)
(662) 627-4131
Entity
Organization
Contact information
Practice address
2245 N STATE STREET, CLARKSDALE, MS 38614
(662) 627-4131
(662) 627-2702
Mailing address
PO BOX 1447, CLARKSDALE, MS 38614
(662) 627-4131
(662) 627-2702
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
07070
MS
208000000X
Pediatrics Physician
07191
MS
208000000X
Pediatrics Physician
Primary
R861078
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
09013997
—
MS
Enumeration date
11/03/2006
Last updated
08/22/2020
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