Provider Demographics
NPI:1104366087
Name:SOUTH MISSISSIPPI NEUROSURGICAL SERVICES, PLLC
Entity Type:Organization
Organization Name:SOUTH MISSISSIPPI NEUROSURGICAL SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:R
Authorized Official - Last Name:BRENT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-579-4440
Mailing Address - Street 1:1212 SOUTH 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-3261
Mailing Address - Country:US
Mailing Address - Phone:601-579-4440
Mailing Address - Fax:601-579-4458
Practice Address - Street 1:1212 SOUTH 28TH AVE
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402
Practice Address - Country:US
Practice Address - Phone:601-475-2430
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-27
Last Update Date:2018-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS09082207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09082OtherMS LICENSE