Healthcare Provider Details

I. General information

NPI: 1922186105
Provider Name (Legal Business Name): LAUREL BONE AND JOINT CLINIC, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 11/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

424 S 13TH AVE
LAUREL MS
39440-4345
US

IV. Provider business mailing address

424 S 13TH AVE
LAUREL MS
39440-4345
US

V. Phone/Fax

Practice location:
  • Phone: 601-649-5990
  • Fax: 601-425-7510
Mailing address:
  • Phone: 601-649-5990
  • Fax: 601-425-7510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. THOMAS R BICKER
Title or Position: CLINIC MANAGER
Credential:
Phone: 601-649-5990