Basic Information
Provider Information | |||||||||
NPI: | 1659533412 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MARKS | ||||||||
FirstName: | TYLER | ||||||||
MiddleName: | G. | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1211 SOUTH GLOSTER | ||||||||
Address2: | SUITE A | ||||||||
City: | TUPELO | ||||||||
State: | MS | ||||||||
PostalCode: | 38801 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6627674200 | ||||||||
FaxNumber: | 6627674204 | ||||||||
Practice Location | |||||||||
Address1: | 1211 SOUTH GLOSTER | ||||||||
Address2: | SUITE A | ||||||||
City: | TUPELO | ||||||||
State: | MS | ||||||||
PostalCode: | 38801 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6627674200 | ||||||||
FaxNumber: | 6627674204 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/01/2008 | ||||||||
LastUpdateDate: | 11/11/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/11/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 23190 | MS | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   | 2086S0105X | 23190 | MS | N |   | Allopathic & Osteopathic Physicians | Surgery | Surgery of the Hand | 207XS0106X | 23190 | MS | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery |
ID Information
ID | Type | State | Issuer | Description | 04722052 | 05 | MS |   | MEDICAID |