Provider Demographics
NPI:1447271713
Name:COLUMBUS ORTHOPEDIC OUTPATIENT
Entity type:Organization
Organization Name:COLUMBUS ORTHOPEDIC OUTPATIENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GINA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-328-1012
Mailing Address - Street 1:640 LEIGH DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39705-3014
Mailing Address - Country:US
Mailing Address - Phone:662-328-7123
Mailing Address - Fax:662-328-7156
Practice Address - Street 1:640 LEIGH DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705-3014
Practice Address - Country:US
Practice Address - Phone:662-328-7123
Practice Address - Fax:662-328-7156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2020-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS25C0001046261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07482223Medicaid
MS490000044Medicare ID - Type UnspecifiedMEDICARE