Provider Demographics
NPI:1295161404
Name:MISSISSIPPI ORTHOPAEDIC INSTITUTE
Entity type:Organization
Organization Name:MISSISSIPPI ORTHOPAEDIC INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:LANCE
Authorized Official - Last Name:JOHANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:228-328-2400
Mailing Address - Street 1:15190 COMMUNITY RD SUITE 120
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503
Mailing Address - Country:US
Mailing Address - Phone:228-328-2400
Mailing Address - Fax:228-328-4200
Practice Address - Street 1:15190 COMMUNITY RD STE 120
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-3484
Practice Address - Country:US
Practice Address - Phone:228-328-2400
Practice Address - Fax:228-328-4200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-19
Last Update Date:2013-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS14698332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04232510Medicaid
MS04232510Medicaid