Provider Demographics
NPI:1730242462
Name:PEDIATRICS & FAMILY PRACTICE OF COLUMBIA, P.A.
Entity type:Organization
Organization Name:PEDIATRICS & FAMILY PRACTICE OF COLUMBIA, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:RYOHWAN
Authorized Official - Last Name:JANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-444-4798
Mailing Address - Street 1:2 W LAKEVIEW DR
Mailing Address - Street 2:SUITE 2
Mailing Address - City:COLUMBIA
Mailing Address - State:MS
Mailing Address - Zip Code:39429-7960
Mailing Address - Country:US
Mailing Address - Phone:601-444-4798
Mailing Address - Fax:601-444-5127
Practice Address - Street 1:2 W LAKEVIEW DR
Practice Address - Street 2:SUITE 2
Practice Address - City:COLUMBIA
Practice Address - State:MS
Practice Address - Zip Code:39429-7960
Practice Address - Country:US
Practice Address - Phone:601-444-4798
Practice Address - Fax:601-444-5127
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-17
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS17888207Q00000X
MS17887208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08502504Medicaid
MS08502504Medicaid