Provider Demographics
NPI:1720506264
Name:ORTHOXPRESS HOLDINGS, LLC
Entity type:Organization
Organization Name:ORTHOXPRESS HOLDINGS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:C
Authorized Official - Last Name:BULLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-534-2298
Mailing Address - Street 1:206 OXFORD RD
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:MS
Mailing Address - Zip Code:38652-3115
Mailing Address - Country:US
Mailing Address - Phone:662-534-2227
Mailing Address - Fax:662-534-2330
Practice Address - Street 1:3952C N GLOSTER ST
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38804-0913
Practice Address - Country:US
Practice Address - Phone:662-350-0737
Practice Address - Fax:662-534-2330
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ORTHOXPRESS HOLDINGS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-09-05
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02654844Medicaid