Provider Demographics
NPI:1962674739
Name:UNIVERSITY SPORTS MEDICINE PLLC
Entity Type:Organization
Organization Name:UNIVERSITY SPORTS MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:G
Authorized Official - Last Name:FERGUSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-234-0424
Mailing Address - Street 1:2401 PROFESSIONAL DR
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-5374
Mailing Address - Country:US
Mailing Address - Phone:662-234-0424
Mailing Address - Fax:662-234-0485
Practice Address - Street 1:2401 PROFESSIONAL DR
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-5374
Practice Address - Country:US
Practice Address - Phone:662-234-0424
Practice Address - Fax:662-234-0485
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-01
Last Update Date:2009-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13319174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00118675Medicaid
MS4127050001Medicare NSC
MSE95072Medicare UPIN