# MID STATE ORTHOPAEDIC & SPORTS MEDICINE CENTER, LLC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Mid-State Orthopaedic & Sports Medicine Center Inc
- **Organization subpart:** No

## Provider details

- **NPI number:** 1104890052
- **Authorized official:** NAKITA C HICKMAN (CREDENTIALING MANAGER)
- **Authorized official phone:** (318) 441-8329

## Contact information

- **Practice address:** 3444 MASONIC DRIVE, ALEXANDRIA, LA 71301
- **Practice address phone:** (318) 473-9556
- **Practice address fax:** (318) 441-8339
- **Mailing address:** 3444 MASONIC DRIVE, ALEXANDRIA, LA 71301
- **Mailing address phone:** (318) 473-9556
- **Mailing address fax:** (318) 441-8339

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207X00000X | Orthopaedic Surgery Physician | — | NULL | Yes |
| 207X00000X | Orthopaedic Surgery Physician | — | — | Yes |
| 208100000X | Physical Medicine & Rehabilitation Physician | — | NULL | — |
| 208100000X | Physical Medicine & Rehabilitation Physician | — | — | — |
| 213E00000X | Podiatrist | — | — | — |
| 225100000X | Physical Therapist | — | NULL | — |
| 225100000X | Physical Therapist | — | — | — |
| 225X00000X | Occupational Therapist | — | NULL | — |
| 225X00000X | Occupational Therapist | — | — | — |

## Other

- **Enumeration date:** 02/16/2006
- **Last updated:** 03/24/2026

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 0570570001 | MEDICARE DME GROUP \# | LA |
| 05 | — | 1946320 | — | LA |
| 01 | — | CD7720 | RAILROAD MEDICARE PALMETT | LA |