Provider Demographics
NPI:1366532038
Name:COLUMBUS OBGYN SPECIALTY CENTER PLLC
Entity type:Organization
Organization Name:COLUMBUS OBGYN SPECIALTY CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:CHILDREY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-240-0095
Mailing Address - Street 1:425 HOSPITAL DR STE 5
Mailing Address - Street 2:P.O. BOX 8700
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39705-1938
Mailing Address - Country:US
Mailing Address - Phone:662-240-0095
Mailing Address - Fax:662-240-0096
Practice Address - Street 1:425 HOSPITAL DR
Practice Address - Street 2:SUITE 5
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705-1901
Practice Address - Country:US
Practice Address - Phone:662-240-0095
Practice Address - Fax:662-240-0096
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02285027Medicaid
MS02285027Medicaid