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General NPI Number Information
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NPI Number | 1235209115
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Entity Type | Organization
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Legal Business Name | MISSISSIPPI FOOT AND SURGICAL CENTER, LLC
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Dates
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Enumeration Date | 11/08/2006
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Last Update Date | 06/19/2008
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Provider Practice Location Address
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Address Line | 1915 DUNBARTON DRIVE
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City | JACKSON
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State | MS
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Zip | 39216
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Country | US
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Telephone | 601-982-3338
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Fax | 601-982-2253
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Provider Business Mailing Address
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Address Line | 1915 DUNBARTON DRIVE
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City | JACKSON
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State | MS
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Zip | 39216
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Country | US
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Telephone | 601-982-3338
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Fax | 601-982-2253
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Authorized Official
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Title or Position | OWNER
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Name | BRYAN TIPTON SULLIVAN
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Credential | DPM
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Telephone | 601-982-3338
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213E00000X
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Taxonomy Name | Podiatrist
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License Number | 80089
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License Number State | MS
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