Provider Demographics
NPI:1326149956
Name:THE NEUROSURGICAL CENTER
Entity Type:Organization
Organization Name:THE NEUROSURGICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WINSTON
Authorized Official - Middle Name:CRAIG
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-349-5660
Mailing Address - Street 1:55 PHYSICIANS LN
Mailing Address - Street 2:SUITE 1
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-9569
Mailing Address - Country:US
Mailing Address - Phone:662-349-5660
Mailing Address - Fax:662-349-5669
Practice Address - Street 1:55 PHYSICIANS LN
Practice Address - Street 2:SUITE 1
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-9569
Practice Address - Country:US
Practice Address - Phone:662-349-5660
Practice Address - Fax:662-349-5669
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD14839207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07659397Medicaid
TN162898OtherBCBS OF TN
TN3707531Medicaid
MS257741290OtherBCBS OF MS
A99353Medicare UPIN
TN3707531Medicaid
MS257741290OtherBCBS OF MS
MS07659397Medicaid