Basic Information
| Provider Information | |||||||||
| NPI: | 1699810069 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EAR NOSE AND THROAT SURGICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 23666 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012004850 | ||||||||
| FaxNumber: | 6012004838 | ||||||||
| Practice Location | |||||||||
| Address1: | 970 LAKELAND DR STE 40 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392164640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012004850 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2007 | ||||||||
| LastUpdateDate: | 08/10/2011 | ||||||||
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| AuthorizedOfficialLastName: | WALLACE | ||||||||
| AuthorizedOfficialFirstName: | MICKEY | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 6018987000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 08819 | MS | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 04387064 | 05 | MS | MEDICAID |