Active NPI
Desiree Buehler Pendergrass, M.D.
- Pediatrics Physician
- Jackson, MS
National Provider Identifier
1255425989
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pediatrics Physician
- License
- 24712
- Practice address
- 2500 N State St
Jackson, MS 39216-4500 - Phone
- (601) 815-8982
- NPI assigned
- Oct 3, 2006
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 4
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pediatrics Physician | 208000000X | H4609 | TX | |
| Public Health & General Preventive Medicine Physician | 2083P0901X | H4609 | TX | |
| Pediatrics Physician | 208000000X | 24712 | MS | Primary |
| Public Health & General Preventive Medicine Physician | 2083P0901X | 24712 | MS |
Addresses
Primary practice location
2500 N State St
Jackson, MS 39216-4500
Mailing address
2500 N State St
Jackson, MS 39216-4500
Phone (601) 815-8982
Other identifiers 7
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 05359595 | Medicaid | MS | |
| 08907561 | Other | TX | NM MEDICAID |
| 8J1510 | Other | TX | MEDICARE |
| 132232307 | Other | TX | TMHP |
| 155349101 | Other | TX | FIRSTCARE MEDICAID |
| 8G6058 | Other | TX | BC/BS |
| 200101350A | Other | TX | OK MEDICARE |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 24712 | MS | MD | Public Health & General Preventive Medicine Physician |
Interoperability endpoints
- desiree.pendergrass@direct.myteamcare.com
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1159833600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1487289600000",
"number": "1255425989",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "2500 N STATE ST",
"city": "JACKSON",
"state": "MS",
"postal_code": "392164500",
"telephone_number": "601-815-8982"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2500 N STATE ST",
"city": "JACKSON",
"state": "MS",
"postal_code": "392164500",
"telephone_number": "601-815-8982"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PENDERGRASS",
"first_name": "DESIREE",
"middle_name": "BUEHLER",
"credential": "M.D.",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2006-10-03",
"last_updated": "2017-02-17",
"status": "A"
},
"taxonomies": [
{
"code": "208000000X",
"taxonomy_group": "",
"desc": "Pediatrics",
"state": "TX",
"license": "H4609",
"primary": false
},
{
"code": "2083P0901X",
"taxonomy_group": "",
"desc": "Preventive Medicine, Public Health & General Preventive Medicine",
"state": "TX",
"license": "H4609",
"primary": false
},
{
"code": "208000000X",
"taxonomy_group": "",
"desc": "Pediatrics",
"state": "MS",
"license": "24712",
"primary": true
},
{
"code": "2083P0901X",
"taxonomy_group": "",
"desc": "Preventive Medicine, Public Health & General Preventive Medicine",
"state": "MS",
"license": "24712",
"primary": false
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "05359595",
"state": "MS"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "NM MEDICAID",
"identifier": "08907561",
"state": "TX"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "MEDICARE",
"identifier": "8J1510",
"state": "TX"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "TMHP",
"identifier": "132232307",
"state": "TX"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "FIRSTCARE MEDICAID",
"identifier": "155349101",
"state": "TX"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BC/BS",
"identifier": "8G6058",
"state": "TX"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "OK MEDICARE",
"identifier": "200101350A",
"state": "TX"
}
],
"endpoints": [],
"other_names": []
}Other providers in Jackson, MS
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 17, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.