NPIMap

Organization Active NPI

King's Daughters Medical Center

Doing business as KDMC Pediatric Adolescent Clinic

  • Rural Health Clinic/Center
  • Brookhaven, MS
National Provider Identifier
1275307902
Registry record updated Nov 13, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
KING'S DAUGHTERS MEDICAL CENTER
Doing business as
KDMC Pediatric Adolescent Clinic
Practice address
509 Brookman Dr.
Brookhaven, MS 39601-2326
Phone
(601) 823-5204
NPI assigned
Nov 13, 2023
Last updated
Nov 13, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 13, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Scott Christensen
Title
Ceo
Phone
(601) 835-9488

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X NU Primary

Addresses

Primary practice location

509 Brookman Dr.
Brookhaven, MS 39601-2326

Mailing address

427 Highway 51 N
Brookhaven, MS 39601-2350
Phone (601) 835-9275

Other names 1

  • KDMC Pediatric Adolescent Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MS

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20240108005144 MS Part A Provider - Rural Health Clinic 3072575539 Practice locations: Brookhaven, MS

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1275307902. Details of each certification follow.

Rural health clinic certification: CCN 258677

Legal name
KINGS DAUGHTERS MEDICAL CENTER
Doing business as
KDMC PEDIATRIC ADOLESCENT CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Apr 10, 2024
Last certification
Apr 10, 2024
Ownership / control type
2B
Organization structure
CorporationNon-profit
Incorporated
Sep 3, 1966 in MS
Enrollment address
509 Brookman Dr
Brookhaven, MS 39601-2326
Related CCNs
250057

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 5

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory
Tax ID family
Kings Daughters Hosp Su11 organizations share this tax ID, including this one

Other organizations with this tax ID 10

Organizations that report the same tax identification number in the National Provider Directory.

Locations

427 Highway 51 N
Brookhaven, MS 39601
Phone (601) 833-6011

Ownership & related parties

All disclosed owners & managing parties 6

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Scott Christensen Individual Corporate OfficerCeo Jan 1, 2024
Corporate DirectorCeo Jan 1, 2024
Operational/Managerial ControlCeo Jan 1, 2024
Peggy King Individual W-2 Managing Employee Jan 1, 2024
Alison March Individual W-2 Managing Employee Jan 1, 2024
Delton Jeffrey Richardson Individual W-2 Managing Employee Jan 1, 2024
Elizabeth Shann Individual W-2 Managing Employee Jan 1, 2024
Adam Moore Individual Operational/Managerial ControlCfo Jan 1, 2024

All facility ownership & control disclosures 2

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
King's Daughters Medical ClinicBrookhaven, MS, CCN 258676 Rural health clinic 5% Or Greater Direct Ownership Interest
Operational/Managerial Control		 Jan 1, 2024
Jan 1, 2024
King's Daughters Primary Care ClinicBrookhaven, MS, CCN 258678 Rural health clinic 5% Or Greater Direct Ownership Interest
Operational/Managerial Control		 Jan 1, 2024
Jan 1, 2024

Owned or controlled facilities with NPI records 2

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1699833600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1699833600000",
    "number": "1275307902",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "427 HIGHWAY 51 N",
            "city": "BROOKHAVEN",
            "state": "MS",
            "postal_code": "396012350",
            "telephone_number": "601-835-9275"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "509 BROOKMAN DR.",
            "city": "BROOKHAVEN",
            "state": "MS",
            "postal_code": "396012326",
            "telephone_number": "601-823-5204"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "KING'S DAUGHTERS MEDICAL CENTER",
        "organizational_subpart": "NO",
        "enumeration_date": "2023-11-13",
        "last_updated": "2023-11-13",
        "certification_date": "2023-11-13",
        "status": "A",
        "authorized_official_last_name": "CHRISTENSEN",
        "authorized_official_first_name": "SCOTT",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "601-835-9488"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "KDMC Pediatric Adolescent Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Brookhaven, MS

Sources for this page

Verify at the official NPI Registry.