Provider Demographics
NPI:1760098750
Name:SOUTHERN BONE & JOINT SPECIALISTS, PA
Entity Type:Organization
Organization Name:SOUTHERN BONE & JOINT SPECIALISTS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:STEWART
Authorized Official - Last Name:MCCRARY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-554-7400
Mailing Address - Street 1:3688 VETERANS MEMORIAL DR STE 200
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-8246
Mailing Address - Country:US
Mailing Address - Phone:601-554-7400
Mailing Address - Fax:
Practice Address - Street 1:1428 AZALEA DR S
Practice Address - Street 2:
Practice Address - City:WIGGINS
Practice Address - State:MS
Practice Address - Zip Code:39577-8195
Practice Address - Country:US
Practice Address - Phone:601-554-7400
Practice Address - Fax:601-554-7499
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHERN BONE & JOINT SPECIALISTS, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-09-16
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015183Medicaid