Basic Information
| Provider Information | |||||||||
| NPI: | 1639426117 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHERN BONE & JOINT SPECIALISTS, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3688 VETERANS MEMORIAL DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | HATTIESBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394018246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6015547400 | ||||||||
| FaxNumber: | 6015547488 | ||||||||
| Practice Location | |||||||||
| Address1: | 7127 HIGHWAY 98 | ||||||||
| Address2: | SUITE 20 | ||||||||
| City: | HATTIESBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6015547400 | ||||||||
| FaxNumber: | 6015547488 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2012 | ||||||||
| LastUpdateDate: | 08/14/2012 | ||||||||
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| AuthorizedOfficialLastName: | BURCKEL | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6015547449 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOUTHERN BONE & JOINT SPECIALISTS, PA | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 09015183 | 05 | MS | MEDICAID |