Provider Demographics
NPI:1639553506
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:CREDENTIALING/PROVIDER ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:JENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLS
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:38801-6535
Mailing Address - Country:US
Mailing Address - Phone:662-767-4200
Mailing Address - Fax:662-767-4204
Practice Address - Street 1:1211 S GLOSTER ST STE A
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-6535
Practice Address - Country:US
Practice Address - Phone:662-767-4200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-10
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07200815Medicaid
MS04722052Medicaid