Basic Information
| Provider Information | |||||||||
| NPI: | 1619526852 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MSK GROUP, PC | ||||||||
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| OtherOrganizationName: | ORTHOSOUTH HOSPITALISTS OF DESOTO | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6077 PRIMACY PKWY STE 140 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381195754 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012591673 | ||||||||
| FaxNumber: | 9012597636 | ||||||||
| Practice Location | |||||||||
| Address1: | 7900 AIRWAYS BLVD BLDG B102 | ||||||||
| Address2: | |||||||||
| City: | SOUTHAVEN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 386714118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6625482965 | ||||||||
| FaxNumber: | 6623499023 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2019 | ||||||||
| LastUpdateDate: | 10/26/2021 | ||||||||
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| AuthorizedOfficialLastName: | GENTRY | ||||||||
| AuthorizedOfficialFirstName: | AMY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 9012591673 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MSK GROUP, PC | ||||||||
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| NPICertificationDate: | 10/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1619526852 | 01 | MS | NPI | OTHER | 0723280014 | 01 | MS | MEDICARE DME | OTHER |