Basic Information
| Provider Information | |||||||||
| NPI: | 1548356983 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OSBORNE | ||||||||
| FirstName: | CLARENCE | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2550 FLOWOOD DRIVE | ||||||||
| Address2: | SUITE 303 | ||||||||
| City: | FLOWOOD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017097700 | ||||||||
| FaxNumber: | 6017097701 | ||||||||
| Practice Location | |||||||||
| Address1: | 2550 FLOWOOD DRIVE | ||||||||
| Address2: | SUITE 303 | ||||||||
| City: | FLOWOOD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017097700 | ||||||||
| FaxNumber: | 6017097701 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 02/23/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | 12145 | MS | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 00115211 | 05 | MS | MEDICAID |