Basic Information
| Provider Information | |||||||||
| NPI: | 1245504026 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MISSISSIPPI EAR NOSE AND THROAT SURGICAL ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 MARSHALL STREET | ||||||||
| Address2: | SUITE 501 | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392021615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017097700 | ||||||||
| FaxNumber: | 6017097701 | ||||||||
| Practice Location | |||||||||
| Address1: | 332 HIGHWAY 12 WEST | ||||||||
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| City: | KOSCIUSKO | ||||||||
| State: | MS | ||||||||
| PostalCode: | 390903209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6622891800 | ||||||||
| FaxNumber: | 6622892486 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2012 | ||||||||
| LastUpdateDate: | 02/27/2012 | ||||||||
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| AuthorizedOfficialLastName: | KAY | ||||||||
| AuthorizedOfficialFirstName: | JANICE | ||||||||
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| AuthorizedOfficialTitleorPosition: | BUSINESS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6017097700 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | C03111 | 01 | MS | MEDICARE GROUP | OTHER |