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General NPI Number Information
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NPI Number | 1295756112
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Entity Type | Organization
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Legal Business Name | SPINE & SPORTS MEDICINE CENTER PLLC
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Dates
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Enumeration Date | 07/23/2006
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Last Update Date | 02/18/2014
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Provider Practice Location Address
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Address Line | 218 S THOMAS ST SUITE 110
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City | TUPELO
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State | MS
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Zip | 38801-5330
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Country | US
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Telephone | 662-842-4919
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Fax | 662-842-9140
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Provider Business Mailing Address
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Address Line | PO BOX 2439 SUITE 110
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City | TUPELO
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State | MS
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Zip | 38803-2439
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Country | US
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Telephone | 662-842-4919
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Fax | 662-842-9140
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Authorized Official
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Title or Position | PHYSICIAN
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Name | VICTOR GRAY
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Credential | M.D.
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Telephone | 662-842-4919
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number | 15561
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License Number State | MS
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