Healthcare Provider Details

I. General information

NPI: 1336949601
Provider Name (Legal Business Name): SPECIALTY ORTHOPEDIC GROUP OF MISSISSIPPI PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2025
Last Update Date: 03/17/2025
Certification Date: 03/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 MEDICAL PLZ STE A
EUPORA MS
39744-4018
US

IV. Provider business mailing address

1211 S GLOSTER ST STE A
TUPELO MS
38801-6548
US

V. Phone/Fax

Practice location:
  • Phone: 662-767-4200
  • Fax:
Mailing address:
  • Phone: 662-767-4200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: KAREN GIBSON
Title or Position: CREDENTIALING
Credential:
Phone: 662-767-4200