Provider Demographics
NPI:1689804668
Name:BIENVILLE ORTHOPAEDIC SPECIALISTS, LLC
Entity Type:Organization
Organization Name:BIENVILLE ORTHOPAEDIC SPECIALISTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LEE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:228-230-2663
Mailing Address - Street 1:6300 E LAKE BLVD STE 301
Mailing Address - Street 2:
Mailing Address - City:VANCLEAVE
Mailing Address - State:MS
Mailing Address - Zip Code:39565-6771
Mailing Address - Country:US
Mailing Address - Phone:228-230-2663
Mailing Address - Fax:228-206-6398
Practice Address - Street 1:15476 DEDEAUX RD
Practice Address - Street 2:SUITE B
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-2637
Practice Address - Country:US
Practice Address - Phone:228-230-2663
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-23
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07338588Medicaid
MS5384230001Medicare NSC
MS07338588Medicaid