Healthcare Provider Details

I. General information

NPI: 1023589017
Provider Name (Legal Business Name): SURGERY CLINIC OF TUPELO PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2018
Last Update Date: 12/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1256 MILITARY ST S
HAMILTON AL
35570-5003
US

IV. Provider business mailing address

499 GLOSTER CREEK VLG STE S1
TUPELO MS
38801-4708
US

V. Phone/Fax

Practice location:
  • Phone: 205-921-6202
  • Fax:
Mailing address:
  • Phone: 662-377-6470
  • Fax: 662-377-6475

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: TERECIA SPAIN
Title or Position: CLINIC ADMINISTRATOR
Credential:
Phone: 662-377-6472