Basic Information
| Provider Information | |||||||||
| NPI: | 1679617773 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MISSISSIPPI EAR, NOSE AND THROAT SURGICAL ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 MARSHALL ST | ||||||||
| Address2: | SUITE 501 | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392021651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017097700 | ||||||||
| FaxNumber: | 6017097701 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 MARSHALL ST | ||||||||
| Address2: | SUITE 501 | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392021651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017097700 | ||||||||
| FaxNumber: | 6017097701 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2007 | ||||||||
| LastUpdateDate: | 07/08/2010 | ||||||||
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| AuthorizedOfficialLastName: | OSBORNE | ||||||||
| AuthorizedOfficialFirstName: | CLARENCE | ||||||||
| AuthorizedOfficialMiddleName: | MICHAEL | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 6017097700 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | MS | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 06420247 | 05 | MS | MEDICAID |