Basic Information
| Provider Information | |||||||||
| NPI: | 1093177685 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPECIALTY ORTHOPEDIC GROUP OF MISSISSIPPI PLLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SOGM OXFORD | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1211 S GLOSTER ST STE A | ||||||||
| Address2: | |||||||||
| City: | TUPELO | ||||||||
| State: | MS | ||||||||
| PostalCode: | 388016535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6627674200 | ||||||||
| FaxNumber: | 6627674204 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 BAPTIST MEMORIAL CIR STE 330 | ||||||||
| Address2: | |||||||||
| City: | OXFORD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 386554477 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6627674200 | ||||||||
| FaxNumber: | 6627674204 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2016 | ||||||||
| LastUpdateDate: | 01/12/2021 | ||||||||
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| AuthorizedOfficialLastName: | RILEY | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
| AuthorizedOfficialMiddleName: | BETH | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6627674200 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 07200815 | 05 | MS | MEDICAID |