Provider Demographics
NPI:1922186105
Name:LAUREL BONE AND JOINT CLINIC, PA
Entity type:Organization
Organization Name:LAUREL BONE AND JOINT CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:R
Authorized Official - Last Name:BICKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-649-5990
Mailing Address - Street 1:424 S 13TH AVE
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39440-4345
Mailing Address - Country:US
Mailing Address - Phone:601-649-5990
Mailing Address - Fax:601-425-7510
Practice Address - Street 1:424 S 13TH AVE
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-4345
Practice Address - Country:US
Practice Address - Phone:601-649-5990
Practice Address - Fax:601-425-7510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSCM7960OtherPALMETTO GBA-RAILROAD MEDICARE
MS0410450001OtherCIGNA GOVERNMENT SERVICES
MS9011200Medicaid
MS9011200Medicaid
MS0410450001Medicare NSC
MSCM7960Medicare PIN