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General NPI Number Information
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NPI Number | 1609320506
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Entity Type | Organization
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Legal Business Name | MID STATE ORTHOPAEDIC & SPORTS MEDICINE CENTER LLC
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Dates
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Enumeration Date | 08/09/2016
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Last Update Date | 04/26/2021
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Provider Practice Location Address
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Address Line | 155 NINTH ST STE A
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City | JENA
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State | LA
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Zip | 71342-3900
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Country | US
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Telephone | 318-473-9556
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Fax | 318-441-8339
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Provider Business Mailing Address
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Address Line | 3444 MASONIC DR
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City | ALEXANDRIA
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State | LA
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Zip | 71301-3615
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Country | US
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Telephone | 318-473-9556
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Fax | 318-441-8339
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Authorized Official
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Title or Position | PRESIDENT
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Name | MARK A DODSON
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Credential | M.D.
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Telephone | 318-473-9556
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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 | 9317843
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License Number State | LA
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Taxonomy #2
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | 9317843
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License Number State | LA
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