Basic Information
| Provider Information | |||||||||
| NPI: | 1053622498 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATHIS | ||||||||
| FirstName: | TAYLOR | ||||||||
| MiddleName: | PHILLIPS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1211 S GLOSTER ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | TUPELO | ||||||||
| State: | MS | ||||||||
| PostalCode: | 38801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6627674200 | ||||||||
| FaxNumber: | 6627674204 | ||||||||
| Practice Location | |||||||||
| Address1: | 1211 S GLOSTER ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | TUPELO | ||||||||
| State: | MS | ||||||||
| PostalCode: | 38801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6627674200 | ||||||||
| FaxNumber: | 6627674204 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2010 | ||||||||
| LastUpdateDate: | 02/01/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 24399 | MS | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 07387848 | 05 | MS | MEDICAID |