Provider Demographics
NPI:1831110725
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:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:M
Authorized Official - Last Name:BURCKEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-554-7499
Mailing Address - Street 1:3688 VETERANS MEMORIAL DRIVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401
Mailing Address - Country:US
Mailing Address - Phone:601-554-7400
Mailing Address - Fax:601-554-7499
Practice Address - Street 1:3688 VETERANS MEMORIAL DRIVE
Practice Address - Street 2:SUITE 200
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401
Practice Address - Country:US
Practice Address - Phone:601-554-7400
Practice Address - Fax:601-554-7499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-23
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS9015183Medicaid
C01026(PTAN)Medicare PIN
MSCI1068Medicare PIN
MS9015183Medicaid
MSC01026Medicare PIN