Healthcare Provider Details

I. General information

NPI: 1447271713
Provider Name (Legal Business Name): COLUMBUS ORTHOPEDIC OUTPATIENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 06/22/2020
Certification Date: 06/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 LEIGH DR
COLUMBUS MS
39705-3014
US

IV. Provider business mailing address

640 LEIGH DR
COLUMBUS MS
39705-3014
US

V. Phone/Fax

Practice location:
  • Phone: 662-328-7123
  • Fax: 662-328-7156
Mailing address:
  • Phone: 662-328-7123
  • Fax: 662-328-7156

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number25C0001046
License Number StateMS

VIII. Authorized Official

Name: GINA WALKER
Title or Position: MANAGER
Credential:
Phone: 662-328-1012