Basic Information
| Provider Information | |||||||||
| NPI: | 1467000927 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPECIALTY ORTHOPEDIC GROUP OF MS, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1211 S GLOSTER ST STE A | ||||||||
| Address2: | |||||||||
| City: | TUPELO | ||||||||
| State: | MS | ||||||||
| PostalCode: | 388016548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6627674200 | ||||||||
| FaxNumber: | 6627674204 | ||||||||
| Practice Location | |||||||||
| Address1: | 118 FAIRFIELD DR | ||||||||
| Address2: | |||||||||
| City: | NEW ALBANY | ||||||||
| State: | MS | ||||||||
| PostalCode: | 386523107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6627674200 | ||||||||
| FaxNumber: | 6627674204 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2019 | ||||||||
| LastUpdateDate: | 09/01/2020 | ||||||||
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| AuthorizedOfficialLastName: | MILL | ||||||||
| AuthorizedOfficialFirstName: | JENNY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING AND ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 6627674200 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SPECIALTY ORTHOPEDIC GROUP OF MS, PLLC | ||||||||
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| NPICertificationDate: | 09/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.