Basic Information
| Provider Information | |||||||||
| NPI: | 1548674658 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHERN BONE & JOINT SPECIALISTS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ADVANCED RX PHARMACY 028 | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3688 VETERANS MEMORIAL DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | HATTIESBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394018246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6015547400 | ||||||||
| FaxNumber: | 6015547499 | ||||||||
| Practice Location | |||||||||
| Address1: | 3688 VETERANS MEMORIAL DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | HATTIESBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6015547449 | ||||||||
| FaxNumber: | 6015547491 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2014 | ||||||||
| LastUpdateDate: | 08/29/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BURCKEL | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6015547400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | 1343411 | MS | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2146374 | 01 | PK | OTHER |