Provider Demographics
NPI:1245258193
Name:TUPELO ORTHOPEDIC CLINIC PA
Entity type:Organization
Organization Name:TUPELO ORTHOPEDIC CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE CLERK/CODER
Authorized Official - Prefix:MRS
Authorized Official - First Name:RHONDA
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-844-5330
Mailing Address - Street 1:PO BOX 1506
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38802-1506
Mailing Address - Country:US
Mailing Address - Phone:662-844-5330
Mailing Address - Fax:662-841-2962
Practice Address - Street 1:808 GARFIELD ST
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-5749
Practice Address - Country:US
Practice Address - Phone:662-844-5330
Practice Address - Fax:662-841-2962
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS9011365Medicaid
MS=========OtherEIN
MS9011365Medicaid
MS1245258193Medicare NSC
MSC00386Medicare PIN