Provider Demographics
NPI:1972694172
Name:ORTHOPEDIC CLINIC OF SOUTHWEST MISSISSIPPI
Entity type:Organization
Organization Name:ORTHOPEDIC CLINIC OF SOUTHWEST MISSISSIPPI
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:SINCLAIR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-249-2701
Mailing Address - Street 1:300 RAWLS DR
Mailing Address - Street 2:SUITE 400
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39648-2877
Mailing Address - Country:US
Mailing Address - Phone:601-684-4613
Mailing Address - Fax:601-249-2226
Practice Address - Street 1:300 RAWLS DR
Practice Address - Street 2:SUITE 400
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648-2877
Practice Address - Country:US
Practice Address - Phone:601-684-4613
Practice Address - Fax:601-249-2226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2007-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07985398Medicaid
MS07985398Medicaid