Healthcare Provider Details

I. General information

NPI: 1114030129
Provider Name (Legal Business Name): TYLERTOWN SURGICAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 HOSPITAL DR
TYLERTOWN MS
39667-2020
US

IV. Provider business mailing address

250 HOSPITAL DR P.0. BOX 465
TYLERTOWN MS
39667-2020
US

V. Phone/Fax

Practice location:
  • Phone: 601-876-4961
  • Fax: 601-876-9172
Mailing address:
  • Phone: 601-876-4961
  • Fax: 601-876-9172

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number07415
License Number StateMS

VIII. Authorized Official

Name: DR. POSAVANIKE S GANARAJ
Title or Position: PRESIDENT
Credential: M.D.
Phone: 601-876-4961