MEDICARE: INTERVENTIONAL SPINE & SPORTS INSTITUTE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208100000X	Physical Medicine & Rehabilitation Physician	20628	MS

General Provider Information

NPI Number	:	1073746152
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTERVENTIONAL SPINE & SPORTS INSTITUTE

Provider Business Mailing Address
First Line	:	PO BOX 17708
Second Line	:
City	:	HATTIESBURG
State	:	MS
Zip	:	39404-7708
Country	:	US
Telephone Number	:	601-296-2552
Fax Number	:	601-296-2552

Provider Business Practice Location Address
First Line	:	105 ASBURY CIR STE B
Second Line	:
City	:	HATTIESBURG
State	:	MS
Zip	:	39402-1397
Country	:	US
Telephone Number	:	601-296-2552
Fax Number	:	601-296-2554

Authorized Official
Title or Position	:	OWNER
Name	:	DR. BRIAN S. TRUSSELL
Credential	:	M.D.
Telephone Number	:	601-296-2552

Provider Enumeration Date	:	08/24/2009
Last Update Date	:	06/30/2010

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