Healthcare Provider Details

I. General information

NPI: 1245646702
Provider Name (Legal Business Name): HAMDI SUKKARIEH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2014
Last Update Date: 06/17/2020
Certification Date: 06/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST
JACKSON MS
39216-4500
US

IV. Provider business mailing address

2500 N STATE STREET CBO-SUITE 4200
JACKSON MS
39216-4500
US

V. Phone/Fax

Practice location:
  • Phone: 319-353-6605
  • Fax: 319-356-8468
Mailing address:
  • Phone: 601-815-2005
  • Fax: 601-815-0434

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XP3100X
TaxonomyPediatric Orthopaedic Surgery Physician
License Number968-L
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number968-L
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: