Healthcare Provider Details

I. General information

NPI: 1699810069
Provider Name (Legal Business Name): EAR NOSE AND THROAT SURGICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 08/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

970 LAKELAND DR STE 40
JACKSON MS
39216-4640
US

IV. Provider business mailing address

PO BOX 23666
JACKSON MS
39225
US

V. Phone/Fax

Practice location:
  • Phone: 601-200-4850
  • Fax:
Mailing address:
  • Phone: 601-200-4850
  • Fax: 601-200-4838

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number08819
License Number StateMS

VIII. Authorized Official

Name: MICKEY P WALLACE
Title or Position: PHYSICIAN
Credential: MD
Phone: 601-898-7000