Healthcare Provider Details

I. General information

NPI: 1619346111
Provider Name (Legal Business Name): SPARTAN ORTHOPAEDICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2015
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6518 GOODMAN RD STE 104
OLIVE BRANCH MS
38654-9809
US

IV. Provider business mailing address

6518 GOODMAN RD STE 104
OLIVE BRANCH MS
38654-9809
US

V. Phone/Fax

Practice location:
  • Phone: 662-420-7350
  • Fax: 662-932-3010
Mailing address:
  • Phone: 662-420-7350
  • Fax: 662-932-3010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER C BULLOCK
Title or Position: PRESIDENT
Credential:
Phone: 662-534-2298