Basic Information
| Provider Information | |||||||||
| NPI: | 1356546295 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHERN BONE& JOINT SPECIALISTS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3688 VETERANS MEMORIAL DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | HATTIESBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394018246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6015547400 | ||||||||
| FaxNumber: | 6015547488 | ||||||||
| Practice Location | |||||||||
| Address1: | 3688 VETERANS MEMORIAL DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | HATTIESBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394018246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6015547400 | ||||||||
| FaxNumber: | 6015547488 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BURCKEL | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6015547400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist | 174400000X | MS | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.