Healthcare Provider Details

I. General information

NPI: 1679905210
Provider Name (Legal Business Name): MISSISSIPPI EAR, NOSE AND THROAT SURGICAL ASSOCIATES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2013
Last Update Date: 05/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2550 FLOWOOD DR SUITE 303
FLOWOOD MS
39232-9303
US

IV. Provider business mailing address

2550 FLOWOOD DR SUITE 303
FLOWOOD MS
39232-9303
US

V. Phone/Fax

Practice location:
  • Phone: 601-709-7707
  • Fax: 601-709-7701
Mailing address:
  • Phone: 601-709-7707
  • Fax: 601-709-7701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number12145
License Number StateMS

VIII. Authorized Official

Name: DR. CLARENCE M OSBORNE
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 601-709-7707