1073746152 NPI number — INTERVENTIONAL SPINE & SPORTS INSTITUTE

Table of content: (NPI 1073746152)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073746152 NPI number — INTERVENTIONAL SPINE & SPORTS INSTITUTE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTERVENTIONAL SPINE & SPORTS INSTITUTE
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:
1073746152
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/30/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 17708
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HATTIESBURG
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39404-7708
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-296-2552
Provider Business Mailing Address Fax Number:
601-296-2552

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
105 ASBURY CIR STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HATTIESBURG
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39402-1397
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-296-2552
Provider Business Practice Location Address Fax Number:
601-296-2554
Provider Enumeration Date:
08/24/2009

Additional Information

Authorized Official

Authorized Official Last Name:
TRUSSELL
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
S.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
601-296-2552

Provider Taxonomy Codes

  • Taxonomy code: 208100000X , with the licence number:  20628 , 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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