Provider Demographics
NPI:1548254493
Name:MISSISSIPPI PAIN PHYSICIANS, PLLC
Entity type:Organization
Organization Name:MISSISSIPPI PAIN PHYSICIANS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:STAGGS
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:601-482-9224
Mailing Address - Street 1:PO BOX 5377
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39302-5377
Mailing Address - Country:US
Mailing Address - Phone:800-897-6169
Mailing Address - Fax:800-897-6170
Practice Address - Street 1:1001 14TH ST
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-4458
Practice Address - Country:US
Practice Address - Phone:601-482-9224
Practice Address - Fax:601-482-9223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-07
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015976Medicaid
MSCA7626OtherMEDICARE RAILROAD
MSCA7626OtherMEDICARE RAILROAD