Provider Demographics
NPI:1013464882
Name:MIDSOUTH SPINE AND PAIN ASSOCIATES PLLC
Entity Type:Organization
Organization Name:MIDSOUTH SPINE AND PAIN ASSOCIATES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NP-C/PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:A
Authorized Official - Last Name:GRIMES
Authorized Official - Suffix:
Authorized Official - Credentials:NP-C
Authorized Official - Phone:662-284-8565
Mailing Address - Street 1:PO BOX 1740
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:MS
Mailing Address - Zip Code:38835-1740
Mailing Address - Country:US
Mailing Address - Phone:662-284-8565
Mailing Address - Fax:662-594-8366
Practice Address - Street 1:3037 CORDER DR
Practice Address - Street 2:
Practice Address - City:CORINTH
Practice Address - State:MS
Practice Address - Zip Code:38834-6216
Practice Address - Country:US
Practice Address - Phone:662-284-8565
Practice Address - Fax:662-594-8366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-08
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS14758174400000X
MS701122363LA2100X
MS16792363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty