=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265328058
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EDWARD BROWN SPECIALTY PARTNERS OF MISSISSIPPI, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2025
-----------------------------------------------------
Last Update Date | 06/17/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4105 HOSPITAL ST
-----------------------------------------------------
City | PASCAGOULA
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39581-5312
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-230-7841
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 820 W 42ND ST STE 2300
-----------------------------------------------------
City | SCOTTSBLUFF
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 69361-5016
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-544-3492
-----------------------------------------------------
Fax | 308-260-0248
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR REVENUE CYCLE MANAGEMENT
-----------------------------------------------------
Name | KRYSTAL RICHARDSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 214-934-7995
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------