Healthcare Provider Details

I. General information

NPI: 1649381104
Provider Name (Legal Business Name): TUPELO PLASTIC SURGERY CLINIC OF TUPELO PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 02/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4381 S EASON BLVD STE 101 LONGTOWN MEDICAL PARK
TUPELO MS
38801-6586
US

IV. Provider business mailing address

450 E PRESIDENT AVE
TUPELO MS
38801-5599
US

V. Phone/Fax

Practice location:
  • Phone: 662-377-6630
  • Fax: 662-377-6635
Mailing address:
  • Phone: 662-377-4685
  • Fax: 662-377-2755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: ROBERT BUCKLEY
Title or Position: MD
Credential:
Phone: 662-377-6630