Healthcare Provider Details

I. General information

NPI: 1013464882
Provider Name (Legal Business Name): MIDSOUTH SPINE AND PAIN ASSOCIATES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2016
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 Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number701122
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number16792
License Number StateMS
# 3
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number14758
License Number StateMS

VIII. Authorized Official

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