Provider Demographics
NPI:1467000927
Name:SPECIALTY ORTHOPEDIC GROUP OF MS, PLLC
Entity Type:Organization
Organization Name:SPECIALTY ORTHOPEDIC GROUP OF MS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING AND ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:JENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:MILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-767-4200
Mailing Address - Street 1:1211 S GLOSTER ST STE A
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-6548
Mailing Address - Country:US
Mailing Address - Phone:662-767-4200
Mailing Address - Fax:662-767-4204
Practice Address - Street 1:118 FAIRFIELD DR
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:MS
Practice Address - Zip Code:38652-3107
Practice Address - Country:US
Practice Address - Phone:662-767-4200
Practice Address - Fax:662-767-4204
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPECIALTY ORTHOPEDIC GROUP OF MS, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-08-28
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty