MEDICARE: SURGERY CLINIC OF COLUMBUS PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208600000X	Surgery Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	SO858PR	OTHER	MS	BLUE CROSS

General Provider Information

NPI Number	:	1073736658
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SURGERY CLINIC OF COLUMBUS PLLC

Provider Business Mailing Address
First Line	:	255 BAPTIST BLVD STE 306
Second Line	:
City	:	COLUMBUS
State	:	MS
Zip	:	39705-2006
Country	:	US
Telephone Number	:	662-328-3441
Fax Number	:	662-328-5540

Provider Business Practice Location Address
First Line	:	255 BAPTIST BLVD STE 306
Second Line	:
City	:	COLUMBUS
State	:	MS
Zip	:	39705-2006
Country	:	US
Telephone Number	:	662-328-3441
Fax Number	:	662-328-5540

Authorized Official
Title or Position	:	PRESIDENT
Name	:	THOMAS L VINSON
Credential	:	MD
Telephone Number	:	662-328-3441

Provider Enumeration Date	:	04/11/2007
Last Update Date	:	12/05/2007

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