Provider Demographics
NPI:1619346111
Name:MITIAS ORTHOPAEDICS, PLLC
Entity Type:Organization
Organization Name:MITIAS ORTHOPAEDICS, PLLC
Other - Org Name:CHAMPION ORTHOPAEDICS, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:C
Authorized Official - Last Name:BULLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-534-2298
Mailing Address - Street 1:6518 GOODMAN RD STE 104
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-9809
Mailing Address - Country:US
Mailing Address - Phone:662-420-7350
Mailing Address - Fax:662-874-5214
Practice Address - Street 1:6518 GOODMAN RD STE 104
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-9809
Practice Address - Country:US
Practice Address - Phone:662-420-7350
Practice Address - Fax:662-874-5214
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MITIAS ORTHOPAEDICS, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-09-15
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02654844Medicaid
MS512G700048OtherMEDICARE PTAN
MS6131110004OtherMEDICARE DME PTAN