Provider Demographics
NPI:1861507311
Name:EAR, NOSE & THROAT PHYSICIANS OF NORTH MISS., P.A.
Entity Type:Organization
Organization Name:EAR, NOSE & THROAT PHYSICIANS OF NORTH MISS., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:MONTGOMERY
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-844-6513
Mailing Address - Street 1:PO BOX 2180
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38803-2180
Mailing Address - Country:US
Mailing Address - Phone:662-844-6513
Mailing Address - Fax:662-844-1113
Practice Address - Street 1:618 PEGRAM DR
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-6322
Practice Address - Country:US
Practice Address - Phone:662-844-6513
Practice Address - Fax:662-844-1113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSCE6078OtherMEDICARE RAILROAD
MS09011431Medicaid
MS09011431Medicaid
MSC00456Medicare ID - Type Unspecified