Healthcare Provider Details

I. General information

NPI: 1477808657
Provider Name (Legal Business Name): MIDSOUTH SPINE AND PAIN ASSOCIATES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2012
Last Update Date: 06/27/2023
Certification Date: 06/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3037 CORDER DR
CORINTH MS
38834-6216
US

IV. Provider business mailing address

PO BOX 1740
CORINTH MS
38835-1740
US

V. Phone/Fax

Practice location:
  • Phone: 662-284-8565
  • Fax: 662-594-8366
Mailing address:
  • Phone: 662-284-8565
  • Fax: 662-594-8366

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number687
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1113
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2148
License Number StateTN
# 4
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number29331
License Number StateTN
# 5
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number14758
License Number StateMS
# 6
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number8118957
License Number StateTN
# 8
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: BRENT ALAN GRIMES
Title or Position: PARTNER
Credential: NP-C
Phone: 662-284-8565