Provider Demographics
NPI:1790067932
Name:NORTH MISSISSIPPI MEDICAL CENTER SERVICES LLC
Entity Type:Organization
Organization Name:NORTH MISSISSIPPI MEDICAL CENTER SERVICES LLC
Other - Org Name:ORTHO TRAUMA SERVICES CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:REPPERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-377-3978
Mailing Address - Street 1:4250 S EASON BLVD
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-6549
Mailing Address - Country:US
Mailing Address - Phone:662-377-5265
Mailing Address - Fax:662-377-5260
Practice Address - Street 1:4250 S EASON BLVD
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-6549
Practice Address - Country:US
Practice Address - Phone:662-377-5265
Practice Address - Fax:662-377-5260
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTH MISSISSIPPI MEDICAL CENTER SERVICES LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-09-14
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09780231Medicaid
MS302G707180Medicare PIN