Provider Demographics
NPI:1689442592
Name:THE COLUMBUS ORTHOPAEDIC CLINIC, P.A.
Entity Type:Organization
Organization Name:THE COLUMBUS ORTHOPAEDIC CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:J
Authorized Official - Last Name:GAVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-370-1014
Mailing Address - Street 1:8613 MS HIGHWAY 12
Mailing Address - Street 2:
Mailing Address - City:ACKERMAN
Mailing Address - State:MS
Mailing Address - Zip Code:39735-8917
Mailing Address - Country:US
Mailing Address - Phone:662-328-1012
Mailing Address - Fax:
Practice Address - Street 1:8613 MS HIGHWAY 12
Practice Address - Street 2:
Practice Address - City:ACKERMAN
Practice Address - State:MS
Practice Address - Zip Code:39735-8917
Practice Address - Country:US
Practice Address - Phone:662-328-1012
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE COLUMBUS ORTHOPAEDIC CLINIC, P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-12-20
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies