Healthcare Provider Details

I. General information

NPI: 1285679076
Provider Name (Legal Business Name): MID-SOUTH SURGERY ASSOCIATES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 11/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

686 W FOREST AVE
JACKSON TN
38301-3940
US

IV. Provider business mailing address

PO BOX 3788
JACKSON TN
38303-3788
US

V. Phone/Fax

Practice location:
  • Phone: 731-660-8759
  • Fax: 731-660-8739
Mailing address:
  • Phone: 731-660-8759
  • Fax: 731-660-8739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: HERBERT L SUTTON
Title or Position: OWNER
Credential: M.D.
Phone: 731-421-4368