Provider Demographics
NPI:1104044494
Name:MISSISSIPPI ORTHOPAEDICS & SPORTS MEDICINE
Entity Type:Organization
Organization Name:MISSISSIPPI ORTHOPAEDICS & SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JANA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:UNDERWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-890-3234
Mailing Address - Street 1:220 STARLYN AVE
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:MS
Mailing Address - Zip Code:38652-2428
Mailing Address - Country:US
Mailing Address - Phone:662-534-2227
Mailing Address - Fax:
Practice Address - Street 1:220 STARLYN AVE
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:MS
Practice Address - Zip Code:38652-2428
Practice Address - Country:US
Practice Address - Phone:662-534-2227
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13955207XP3100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XP3100XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryPediatric Orthopaedic SurgeryGroup - Single Specialty