Provider Demographics
NPI:1770687881
Name:CAPITAL ORTHOPAEDIC CLINIC, PLLC
Entity Type:Organization
Organization Name:CAPITAL ORTHOPAEDIC CLINIC, PLLC
Other - Org Name:CAPITAL ORTHOPAEDIC & SPORTS MEDICINE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:G
Authorized Official - Last Name:DULSKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-987-8200
Mailing Address - Street 1:PO BOX 30594
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28230-0594
Mailing Address - Country:US
Mailing Address - Phone:601-987-8200
Mailing Address - Fax:601-987-8211
Practice Address - Street 1:104 BURNEY DR
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-6621
Practice Address - Country:US
Practice Address - Phone:601-987-8200
Practice Address - Fax:601-987-8211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-11
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13058207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09012262Medicaid
MSC03444Medicare PIN
MS5976860001Medicare NSC