Organization
EAR NOSE AND THROAT SURGICAL GROUP
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MICKEY P WALLACE MD (PHYSICIAN)
(601) 898-7000
Entity
Organization
Contact information
Practice address
970 LAKELAND DR STE 40, JACKSON, MS 39216-4640
(601) 200-4850
Mailing address
PO BOX 23666, JACKSON, MS 39225
(601) 200-4850
(601) 200-4838
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
08819
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
04387064
—
MS
Enumeration date
02/21/2007
Last updated
08/10/2011
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