Provider Demographics
NPI:1437299344
Name:MISSISSIPPI ORTHOPAEDICS & SPORTS MEDICINE, PLLC
Entity Type:Organization
Organization Name:MISSISSIPPI ORTHOPAEDICS & SPORTS MEDICINE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:RITA
Authorized Official - Middle Name:B
Authorized Official - Last Name:CHRISTIAN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:662-536-0900
Mailing Address - Street 1:PO BOX 1107
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-0111
Mailing Address - Country:US
Mailing Address - Phone:662-536-0900
Mailing Address - Fax:662-536-0914
Practice Address - Street 1:391 SOUTHCREST CIR
Practice Address - Street 2:SUITE 205
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-6730
Practice Address - Country:US
Practice Address - Phone:662-536-0900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2013-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11962207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00119607Medicaid
MS00574531Medicaid
F16030Medicare UPIN
MS00119607Medicaid
G20364Medicare UPIN
MS200000495Medicare ID - Type Unspecified
31798351Medicare PIN
MS00574531Medicaid
MS5612720001Medicare NSC
30663241Medicare PIN