Healthcare Provider Details

I. General information

NPI: 1881712057
Provider Name (Legal Business Name): EAR NOSE & THROAT SURGICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

764 LAKELAND DRIVE SUITE 200
JACKSON MS
39216-4617
US

IV. Provider business mailing address

764 LAKELAND DRIVE SUITE 200
JACKSON MS
39216-4617
US

V. Phone/Fax

Practice location:
  • Phone: 601-982-0611
  • Fax: 601-321-1647
Mailing address:
  • Phone: 601-982-0611
  • Fax: 601-321-1647

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MRS. KAREN D ALFORD
Title or Position: CFO ADMINISTRATOR
Credential: CPA
Phone: 601-321-1626