Basic Information
Provider Information | |||||||||
NPI: | 1760098750 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SOUTHERN BONE & JOINT SPECIALISTS, PA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3688 VETERANS MEMORIAL DR STE 200 | ||||||||
Address2: |   | ||||||||
City: | HATTIESBURG | ||||||||
State: | MS | ||||||||
PostalCode: | 394018246 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6015547400 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1428 AZALEA DR S | ||||||||
Address2: |   | ||||||||
City: | WIGGINS | ||||||||
State: | MS | ||||||||
PostalCode: | 395778195 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6015547400 | ||||||||
FaxNumber: | 6015547499 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/16/2020 | ||||||||
LastUpdateDate: | 09/16/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MCCRARY | ||||||||
AuthorizedOfficialFirstName: | STEPHANIE | ||||||||
AuthorizedOfficialMiddleName: | STEWART | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 6015547400 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | SOUTHERN BONE & JOINT SPECIALISTS, PA | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/16/2020 |
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 |