1619010691 NPI number — ALLSTAR ORTHOPEDICS PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619010691 NPI number — ALLSTAR ORTHOPEDICS PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ALLSTAR ORTHOPEDICS 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:
1619010691
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/09/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
ALLSTAR ORTHOPEDICS, PLLC
Provider Second Line Business Mailing Address:
P O BOX 1918
Provider Business Mailing Address City Name:
GAUTIER
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39553
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
228-762-3993
Provider Business Mailing Address Fax Number:
228-762-3839

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2725 ANDREW AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PASCAGOULA
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39567-1815
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
228-762-3993
Provider Business Practice Location Address Fax Number:
228-762-3839
Provider Enumeration Date:
02/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BLACK
Authorized Official First Name:
ARTHUR
Authorized Official Middle Name:
DEWAYNE
Authorized Official Title or Position:
OWNER ORTHOPEDIC SURGEON
Authorized Official Telephone Number:
228-762-3993

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  15591 , 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)

  • Identifier: 03504519 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 573510548D . This is a "BLUE CROSS" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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