Provider Demographics
NPI:1508561978
Name:SPECIALTY ORTHOPEDIC GROUP OF MISSISSIPPI PLLC
Entity Type:Organization
Organization Name:SPECIALTY ORTHOPEDIC GROUP OF MISSISSIPPI PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMIN ASST/ CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:GIBSON
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:
Practice Address - Street 1:910 MARY VANCE DR
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-6226
Practice Address - Country:US
Practice Address - Phone:662-767-4200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPECIALTY ORTHOPEDIC GROUP OF MISSISSIPPI PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-04-04
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty