Basic Information
Provider Information | |||||||||
NPI: | 1578719225 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ORTHOPAEDIC CLINICS OF SW MISSISSIPPI PA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 300 RAWLS DR | ||||||||
Address2: | MEDICAL ARTS BUILDING SUITE 400 | ||||||||
City: | MCCOMB | ||||||||
State: | MS | ||||||||
PostalCode: | 396482877 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6016844613 | ||||||||
FaxNumber: | 6012492287 | ||||||||
Practice Location | |||||||||
Address1: | 300 RAWLS DR | ||||||||
Address2: | MEDICAL ARTS BUILDING SUITE 400 | ||||||||
City: | MCCOMB | ||||||||
State: | MS | ||||||||
PostalCode: | 396482877 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6016844613 | ||||||||
FaxNumber: | 6012492287 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/13/2008 | ||||||||
LastUpdateDate: | 08/13/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JEFFCOAT | ||||||||
AuthorizedOfficialFirstName: | BYRON | ||||||||
AuthorizedOfficialMiddleName: | THOMAS | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 6016844613 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 06737 | MS | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |   |
No ID Information.