Basic Information
| Provider Information | |||||||||
| NPI: | 1972694172 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ORTHOPEDIC CLINIC OF SOUTHWEST MISSISSIPPI | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 RAWLS DR | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | MCCOMB | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396482877 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6016844613 | ||||||||
| FaxNumber: | 6012492226 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 RAWLS DR | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | MCCOMB | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396482877 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6016844613 | ||||||||
| FaxNumber: | 6012492226 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2006 | ||||||||
| LastUpdateDate: | 08/28/2007 | ||||||||
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| AuthorizedOfficialLastName: | SINCLAIR | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6012492701 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0005X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 07985398 | 05 | MS | MEDICAID |