Provider Demographics
NPI:1215025358
Name:WEATHERLY SPORTS MEDICINE & FAMILY ORTHOPAEDICS, PA
Entity Type:Organization
Organization Name:WEATHERLY SPORTS MEDICINE & FAMILY ORTHOPAEDICS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WALLACE
Authorized Official - Middle Name:W
Authorized Official - Last Name:WEATHERLY
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:601-856-5633
Mailing Address - Street 1:PO BOX 1154
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39130-1154
Mailing Address - Country:US
Mailing Address - Phone:601-981-5633
Mailing Address - Fax:601-981-1844
Practice Address - Street 1:1801 CRANE RIDGE DR
Practice Address - Street 2:SUITE C
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4902
Practice Address - Country:US
Practice Address - Phone:601-981-5633
Practice Address - Fax:601-981-1844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2014-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07105081Medicaid
MS07105081Medicaid