Healthcare Provider Details

I. General information

NPI: 1679617773
Provider Name (Legal Business Name): MISSISSIPPI EAR, NOSE AND THROAT SURGICAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 07/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 MARSHALL ST SUITE 501
JACKSON MS
39202-1651
US

IV. Provider business mailing address

501 MARSHALL ST SUITE 501
JACKSON MS
39202-1651
US

V. Phone/Fax

Practice location:
  • Phone: 601-709-7700
  • Fax: 601-709-7701
Mailing address:
  • Phone: 601-709-7700
  • Fax: 601-709-7701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number StateMS

VIII. Authorized Official

Name: MR. CLARENCE MICHAEL OSBORNE
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 601-709-7700