1295827004 NPI number — NORTH MISSISSIPPI SPINE CENTER, INC

Table of content: (NPI 1295827004)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295827004 NPI number — NORTH MISSISSIPPI SPINE CENTER, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTH MISSISSIPPI SPINE CENTER, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
NORTH MISSISSIPPI SPINE CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295827004
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/24/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1204
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OXFORD
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38655-1204
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-563-7728
Provider Business Mailing Address Fax Number:
662-563-4888

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
109 EUREKA STREET
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
BATESVILLE
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38606
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-563-7728
Provider Business Practice Location Address Fax Number:
662-563-4888
Provider Enumeration Date:
09/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HARMON
Authorized Official First Name:
BRIDGETTE
Authorized Official Middle Name:
ROCKETTE
Authorized Official Title or Position:
MANAGER OF CLINICAL SERVICES
Authorized Official Telephone Number:
662-563-7728

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  25C0001060 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 293D00000X , with the licence number: 542011 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 335E00000X , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 04584863 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00122658 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 05001777 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 05621095 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5521760001 . This is a "NSCSSUPP DMEPOS" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 00015663 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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