Healthcare Provider Details

I. General information

NPI: 1568415560
Provider Name (Legal Business Name): MISSISSIPPI SPORTS MEDICINE & ORTHOPAEDIC CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 E FORTIFICATION ST
JACKSON MS
39202-2442
US

IV. Provider business mailing address

1325 E FORTIFICATION ST
JACKSON MS
39202-2442
US

V. Phone/Fax

Practice location:
  • Phone: 601-949-9106
  • Fax: 601-351-5980
Mailing address:
  • Phone: 601-354-4488
  • Fax: 601-351-5980

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: ALLEN ANDERSON
Title or Position: CEO
Credential:
Phone: 601-354-4488