Provider Demographics
NPI:1093177685
Name:SPECIALTY ORTHOPEDIC GROUP OF MISSISSIPPI PLLC
Entity Type:Organization
Organization Name:SPECIALTY ORTHOPEDIC GROUP OF MISSISSIPPI PLLC
Other - Org Name:SOGM OXFORD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:BETH
Authorized Official - Last Name:RILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-767-4200
Mailing Address - Street 1:1211 S GLOSTER ST STE A
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-6535
Mailing Address - Country:US
Mailing Address - Phone:662-767-4200
Mailing Address - Fax:662-767-4204
Practice Address - Street 1:100 BAPTIST MEMORIAL CIR STE 330
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-4477
Practice Address - Country:US
Practice Address - Phone:662-767-4200
Practice Address - Fax:662-767-4204
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-23
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07200815Medicaid