Healthcare Provider Details

I. General information

NPI: 1023734878
Provider Name (Legal Business Name): ENT SURGICAL GROUP, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2022
Last Update Date: 10/13/2022
Certification Date: 10/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

138 PARK PLACE BLVD
MADISON MS
39110
US

IV. Provider business mailing address

138 PARK PLACE BLVD
MADISON MS
39110
US

V. Phone/Fax

Practice location:
  • Phone: 601-898-7500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State

VIII. Authorized Official

Name: KYLE GORDON
Title or Position: OWNER
Credential: MD
Phone: 601-898-7500