Provider Demographics
NPI:1659575728
Name:MISSISSIPPI ORTHOPAEDIC INSTITUTE
Entity Type:Organization
Organization Name:MISSISSIPPI ORTHOPAEDIC INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:F
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:228-328-2400
Mailing Address - Street 1:15190 COMMUNITY RD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-3484
Mailing Address - Country:US
Mailing Address - Phone:228-328-2400
Mailing Address - Fax:228-328-4200
Practice Address - Street 1:15190 COMMUNITY RD
Practice Address - Street 2:SUITE 120
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-3484
Practice Address - Country:US
Practice Address - Phone:228-328-2400
Practice Address - Fax:228-328-4200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-13
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS14698174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04232510Medicaid
MS04232510Medicaid
MS5707330001Medicare NSC