Healthcare Provider Details

I. General information

NPI: 1336917244
Provider Name (Legal Business Name): THE COLUMBUS ORTHOPAEDIC CLINIC, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2023
Last Update Date: 12/20/2023
Certification Date: 12/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17540 E MAIN ST
LOUISVILLE MS
39339-2772
US

IV. Provider business mailing address

17540 E MAIN ST
LOUISVILLE MS
39339-2772
US

V. Phone/Fax

Practice location:
  • Phone: 662-328-1012
  • Fax:
Mailing address:
  • Phone: 662-328-1012
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: TAMMY J GAVIN
Title or Position: CREDENTIALING
Credential:
Phone: 662-370-1014