NPIMap

Organization Active NPI

Ear Nose and Throat Surgical Group

  • Specialist
  • Jackson, MS
National Provider Identifier
1699810069
Registry record updated Aug 10, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
SpecialistTaxonomy code 174400000X
License
08819 Issued in MS
Legal business name
EAR NOSE AND THROAT SURGICAL GROUP
Practice address
970 Lakeland Dr Ste 40
Jackson, MS 39216-4640
Phone
(601) 200-4850
NPI assigned
Feb 21, 2007
Last updated
Aug 10, 2011By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 10, 2011

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mickey P Wallace, MD
Title
Physician
Phone
(601) 898-7000

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
SpecialistGroup: 193200000X MULTI-SPECIALTY GROUP 174400000X 08819 MS Primary

Addresses

Primary practice location

970 Lakeland Dr Ste 40
Jackson, MS 39216-4640

Mailing address

PO Box 23666
Jackson, MS 39225
Phone (601) 200-4850

Other identifiers 1

IdentifierTypeStateIssuer
04387064MedicaidMS

National Provider Directory

National Provider Directory
Tax ID family
St Dominic Medical Associates LLC28 organizations share this tax ID, including this one

Other organizations with this tax ID 27

Organizations that report the same tax identification number in the National Provider Directory.

View all 27

Locations

680 Highway 51
Ste B
Ridgeland, MS 39157
Phone (601) 856-0805

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1172016000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1312934400000",
    "number": "1699810069",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 23666",
            "city": "JACKSON",
            "state": "MS",
            "postal_code": "39225",
            "telephone_number": "601-200-4850",
            "fax_number": "601-200-4838"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "970 LAKELAND DR STE 40",
            "city": "JACKSON",
            "state": "MS",
            "postal_code": "392164640",
            "telephone_number": "601-200-4850"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EAR NOSE AND THROAT SURGICAL GROUP",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-02-21",
        "last_updated": "2011-08-10",
        "status": "A",
        "authorized_official_last_name": "WALLACE",
        "authorized_official_first_name": "MICKEY",
        "authorized_official_middle_name": "P",
        "authorized_official_title_or_position": "PHYSICIAN",
        "authorized_official_telephone_number": "601-898-7000",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "174400000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Specialist",
            "state": "MS",
            "license": "08819",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "04387064",
            "state": "MS"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Jackson, MS

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 10, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.