=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972791978
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPARTAN ORTHOPAEDICS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/04/2007
-----------------------------------------------------
Last Update Date | 03/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 206 OXFORD RD
-----------------------------------------------------
City | NEW ALBANY
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38652
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-534-2227
-----------------------------------------------------
Fax | 662-534-2330
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 15580
-----------------------------------------------------
City | BELFAST
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04915-4050
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-534-2227
-----------------------------------------------------
Fax | 662-534-2330
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JENNIFER C BULLOCK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 662-534-2298
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------