Healthcare Provider Details

I. General information

NPI: 1891459616
Provider Name (Legal Business Name): ORTHO SPORT AND SPINE PHYSICIANS JACKSON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2021
Last Update Date: 10/27/2021
Certification Date: 10/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4316 OLD CANTON RD
JACKSON MS
39211-5995
US

IV. Provider business mailing address

5788 ROSWELL RD STE 100
ATLANTA GA
30328-4904
US

V. Phone/Fax

Practice location:
  • Phone: 678-752-7246
  • Fax:
Mailing address:
  • Phone: 678-752-7246
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: FAITH A BELTZHOOVER
Title or Position: REVENUE CYCLE MANAGEMENT DIRECTOR
Credential:
Phone: 678-752-7246