Provider Demographics
NPI:1235240813
Name:NORTH MISSISSIPPI AMBULATORY SURGERY CENTER LLC
Entity Type:Organization
Organization Name:NORTH MISSISSIPPI AMBULATORY SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-377-4700
Mailing Address - Street 1:450 E PRESIDENT AVE
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-5599
Mailing Address - Country:US
Mailing Address - Phone:662-377-4685
Mailing Address - Fax:662-377-2755
Practice Address - Street 1:589 GARFIELD ST
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-6301
Practice Address - Country:US
Practice Address - Phone:662-377-4700
Practice Address - Fax:662-377-3101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD00074007Medicaid