Healthcare Provider Details

I. General information

NPI: 1790265627
Provider Name (Legal Business Name): MISSISSIPPI BRAIN AND SPINE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2018
Last Update Date: 08/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 LAYFAIR DRIVE STE 120
FLOWOOD MS
39232
US

IV. Provider business mailing address

200 RITTENHOUSE CIRCLE EAST BUILDING STE 5
BRISTOL PA
19007
US

V. Phone/Fax

Practice location:
  • Phone: 888-590-0808
  • Fax: 866-740-4689
Mailing address:
  • Phone: 888-590-0808
  • Fax: 866-740-4689

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number15123
License Number StateMS

VIII. Authorized Official

Name: MACKENZIE HAHN
Title or Position: NCPDP COORDINATOR
Credential:
Phone: 888-590-0808