1295756112 NPI number — SPINE & SPORTS MEDICINE CENTER PLLC

Table of content: (NPI 1295756112)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295756112 NPI number — SPINE & SPORTS MEDICINE CENTER PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPINE & SPORTS MEDICINE CENTER PLLC
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:
Provider Other Organization Name Type Code:
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:
1295756112
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/18/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2439
Provider Second Line Business Mailing Address:
SUITE 110
Provider Business Mailing Address City Name:
TUPELO
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38803-2439
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-842-4919
Provider Business Mailing Address Fax Number:
662-842-9140

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
218 S THOMAS ST
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
TUPELO
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38801-5330
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-842-4919
Provider Business Practice Location Address Fax Number:
662-842-9140
Provider Enumeration Date:
07/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GRAY
Authorized Official First Name:
VICTOR
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
662-842-4919

Provider Taxonomy Codes

  • Taxonomy code: 208100000X , with the licence number:  15561 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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