Provider Demographics
NPI:1770743031
Name:NEWSOUTH NEUROSPINE, LLC
Entity type:Organization
Organization Name:NEWSOUTH NEUROSPINE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:TAVARES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-983-2859
Mailing Address - Street 1:PO BOX 24537
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-4537
Mailing Address - Country:US
Mailing Address - Phone:877-554-4257
Mailing Address - Fax:601-983-2845
Practice Address - Street 1:2470 FLOWOOD DR
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9019
Practice Address - Country:US
Practice Address - Phone:877-554-4257
Practice Address - Fax:601-983-2845
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NEWSOUTH NEUROSPINE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-06-11
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS261QP3300X, 261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00181071Medicaid
MS00181071Medicaid
MS6164110001Medicare NSC
MS25C0001072Medicare Oscar/Certification