Organization
WEATHERLY SPORTS MEDICINE & FAMILY ORTHOPAEDICS, PA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. WALLACE W WEATHERLY III M.D. (PHYSICIAN/OWNER)
(601) 856-5633
Entity
Organization
Contact information
Practice address
1801 CRANE RIDGE DR, SUITE C, JACKSON, MS 39216-4902
(601) 981-5633
(601) 981-1844
Mailing address
PO BOX 1154, MADISON, MS 39130-1154
(601) 981-5633
(601) 981-1844
Taxonomy
Speciality
Code
Description
License number
State
207X00000X
Orthopaedic Surgery Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
07105081
—
MS
Enumeration date
10/11/2006
Last updated
03/28/2014
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