Provider Demographics
NPI:1679617773
Name:MISSISSIPPI EAR, NOSE AND THROAT SURGICAL ASSOCIATES
Entity type:Organization
Organization Name:MISSISSIPPI EAR, NOSE AND THROAT SURGICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:CLARENCE
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:OSBORNE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-709-7700
Mailing Address - Street 1:501 MARSHALL ST
Mailing Address - Street 2:SUITE 501
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-1651
Mailing Address - Country:US
Mailing Address - Phone:601-709-7700
Mailing Address - Fax:601-709-7701
Practice Address - Street 1:501 MARSHALL ST
Practice Address - Street 2:SUITE 501
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-1651
Practice Address - Country:US
Practice Address - Phone:601-709-7700
Practice Address - Fax:601-709-7701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06420247Medicaid
MS06420247Medicaid