MEDICARE: SPARTAN ORTHOPAEDICS, LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	363L00000X	Nurse Practitioner
2	363A00000X	Physician Assistant
3	207X00000X	Orthopaedic Surgery Physician

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	6131110004	OTHER	MS	MEDICARE DME PTAN
3	512G700048	OTHER	MS	MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1619346111
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPARTAN ORTHOPAEDICS, LLC

Provider Business Mailing Address
First Line	:	6518 GOODMAN RD STE 104
Second Line	:
City	:	OLIVE BRANCH
State	:	MS
Zip	:	38654-9809
Country	:	US
Telephone Number	:	662-420-7350
Fax Number	:	662-932-3010

Provider Business Practice Location Address
First Line	:	6518 GOODMAN RD STE 104
Second Line	:
City	:	OLIVE BRANCH
State	:	MS
Zip	:	38654-9809
Country	:	US
Telephone Number	:	662-420-7350
Fax Number	:	662-932-3010

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JENNIFER C BULLOCK
Credential	:
Telephone Number	:	662-534-2298

Provider Enumeration Date	:	09/15/2015
Last Update Date	:	03/10/2026

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Directions to “SPARTAN ORTHOPAEDICS, LLC ” Practice Location

Language	Start Address	Practice Location

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