Healthcare Provider Details

I. General information

NPI: 1346211976
Provider Name (Legal Business Name): MISSISSIPPI SURGICAL SPECIALTIES CENTER PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2006
Last Update Date: 07/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 RIVER ROAD
GREENWOOD MS
38930-1410
US

IV. Provider business mailing address

PO BOX 10117
GREENWOOD MS
38930-0117
US

V. Phone/Fax

Practice location:
  • Phone: 662-453-9305
  • Fax: 662-451-5157
Mailing address:
  • Phone: 662-453-9305
  • Fax: 662-451-5157

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number03952
License Number StateMS

VIII. Authorized Official

Name: ANNIE SMITH
Title or Position: SUPERVISOR
Credential: CCS-P, CCA
Phone: 662-453-9305