Basic Information
| Provider Information | |||||||||
| NPI: | 1790067932 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTH MISSISSIPPI MEDICAL CENTER SERVICES LLC | ||||||||
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| OtherOrganizationName: | ORTHO TRAUMA SERVICES CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4250 S EASON BLVD | ||||||||
| Address2: | |||||||||
| City: | TUPELO | ||||||||
| State: | MS | ||||||||
| PostalCode: | 388016549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6623775265 | ||||||||
| FaxNumber: | 6623775260 | ||||||||
| Practice Location | |||||||||
| Address1: | 4250 S EASON BLVD | ||||||||
| Address2: | |||||||||
| City: | TUPELO | ||||||||
| State: | MS | ||||||||
| PostalCode: | 388016549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6623775265 | ||||||||
| FaxNumber: | 6623775260 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2011 | ||||||||
| LastUpdateDate: | 08/07/2012 | ||||||||
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| AuthorizedOfficialLastName: | REPPERT | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6623773978 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NORTH MISSISSIPPI MEDICAL CENTER SERVICES LLC | ||||||||
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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 | 09780231 | 05 | MS | MEDICAID |