Provider Demographics
NPI:1346211539
Name:SURGERY CLINIC OF TUPELO PA
Entity Type:Organization
Organization Name:SURGERY CLINIC OF TUPELO PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TERECIA
Authorized Official - Middle Name:
Authorized Official - Last Name:SPAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-377-6472
Mailing Address - Street 1:454 E PRESIDENT AVE
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-5501
Mailing Address - Country:US
Mailing Address - Phone:662-377-6470
Mailing Address - Fax:662-377-6475
Practice Address - Street 1:499 GLOSTER CREEK VLG STE S1
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-4708
Practice Address - Country:US
Practice Address - Phone:662-377-6470
Practice Address - Fax:662-377-6475
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-27
Last Update Date:2018-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09013129Medicaid
MS09013129Medicaid