Provider Demographics
NPI:1245504026
Name:MISSISSIPPI EAR NOSE AND THROAT SURGICAL ASSOCIATES
Entity type:Organization
Organization Name:MISSISSIPPI EAR NOSE AND THROAT SURGICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:
Authorized Official - Last Name:KAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-709-7700
Mailing Address - Street 1:501 MARSHALL STREET
Mailing Address - Street 2:SUITE 501
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-1615
Mailing Address - Country:US
Mailing Address - Phone:601-709-7700
Mailing Address - Fax:601-709-7701
Practice Address - Street 1:332 HIGHWAY 12 WEST
Practice Address - Street 2:
Practice Address - City:KOSCIUSKO
Practice Address - State:MS
Practice Address - Zip Code:39090-3209
Practice Address - Country:US
Practice Address - Phone:662-289-1800
Practice Address - Fax:662-289-2486
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-27
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSC03111OtherMEDICARE GROUP