Basic Information
| Provider Information | |||||||||
| NPI: | 1821204736 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MISSISSIPPI EAR, NOSE AND THROAT SURGICAL ASSOCIATES, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2550 FLOWOOD DR STE 303 | ||||||||
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| City: | FLOWOOD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392329306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017097700 | ||||||||
| FaxNumber: | 6017097701 | ||||||||
| Practice Location | |||||||||
| Address1: | 161 RIVER OAKS DRIVE | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | MADISON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017097700 | ||||||||
| FaxNumber: | 6017097701 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2007 | ||||||||
| LastUpdateDate: | 05/08/2021 | ||||||||
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| AuthorizedOfficialLastName: | HINES | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | PEYTON | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 6625717129 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 04/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 1023455169 | 01 | NPI | OTHER | 02652740 | 05 | MS | MEDICAID |