Healthcare Provider Details

I. General information

NPI: 1245504026
Provider Name (Legal Business Name): MISSISSIPPI EAR NOSE AND THROAT SURGICAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2012
Last Update Date: 02/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

332 HIGHWAY 12 WEST
KOSCIUSKO MS
39090-3209
US

IV. Provider business mailing address

501 MARSHALL STREET SUITE 501
JACKSON MS
39202-1615
US

V. Phone/Fax

Practice location:
  • Phone: 662-289-1800
  • Fax: 662-289-2486
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 State

VIII. Authorized Official

Name: JANICE KAY
Title or Position: BUSINESS MANAGER
Credential:
Phone: 601-709-7700