Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207XS0114X | Adult Reconstructive Orthopaedic Surgeon | 20138 | MS |
NPI | 1003951724 |
---|---|
Provider Name | Dr. Trevor Reed Pickering |
First Address | Jackson, MS 39202-2442 |
Second Address | Jackson, MS 39202-2442 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/02/2007 |
Last Update Date | 17/11/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
01239255 | (05) | MS |
P00759915 | MEDICARE RR (01) | MS |