Basic Information
| Provider Information | |||||||||
| NPI: | 1790755320 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ORTHOPAEDIC INSTITUTE OF NORTH MISSISSIPPI, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 499 GLOSTER CREEK VLG STE G1 | ||||||||
| Address2: | |||||||||
| City: | TUPELO | ||||||||
| State: | MS | ||||||||
| PostalCode: | 388014751 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6623772663 | ||||||||
| FaxNumber: | 6628405856 | ||||||||
| Practice Location | |||||||||
| Address1: | 499 GLOSTER CREEK VLG STE G1 | ||||||||
| Address2: | |||||||||
| City: | TUPELO | ||||||||
| State: | MS | ||||||||
| PostalCode: | 388014751 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6623772663 | ||||||||
| FaxNumber: | 6628405856 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2006 | ||||||||
| LastUpdateDate: | 12/09/2021 | ||||||||
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| AuthorizedOfficialLastName: | SOUTHWORTH | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | MD | ||||||||
| AuthorizedOfficialTelephone: | 6623772663 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 12/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XS0106X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery | 207XX0005X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 207X00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 09016127 | 05 | MS | MEDICAID |