Basic Information
| Provider Information | |||||||||
| NPI: | 1568415560 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MISSISSIPPI SPORTS MEDICINE & ORTHOPAEDIC CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1325 E FORTIFICATION ST | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392022442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013544488 | ||||||||
| FaxNumber: | 6013515980 | ||||||||
| Practice Location | |||||||||
| Address1: | 1325 E FORTIFICATION ST | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392022442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019499106 | ||||||||
| FaxNumber: | 6013515980 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 07/27/2022 | ||||||||
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| AuthorizedOfficialLastName: | SILVERMAN | ||||||||
| AuthorizedOfficialFirstName: | GLEN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6013544488 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | CB3252 | 01 | MS | MEDICARE RR GROUP NUMBER | OTHER | 09013483 | 05 | MS | MEDICAID | 374507100 | 01 | MS | ACS/DEPT. OF LABOR | OTHER |