MEDICARE: MEDICAL FOUNDATION OF CENTRAL MISSISSIPPI, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1942424734
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDICAL FOUNDATION OF CENTRAL MISSISSIPPI, INC

Provider Business Mailing Address
First Line	:	1513 LAKELAND DR
Second Line	:	SUITE 200
City	:	JACKSON
State	:	MS
Zip	:	39216-4829
Country	:	US
Telephone Number	:	601-968-1377
Fax Number	:	601-292-4262

Provider Business Practice Location Address
First Line	:	1513 LAKELAND DR
Second Line	:	SUITE 200
City	:	JACKSON
State	:	MS
Zip	:	39216-4829
Country	:	US
Telephone Number	:	601-968-1377
Fax Number	:	601-292-4262

Authorized Official
Title or Position	:	DIRECTOR OF CLINIC ADMINISTRATION
Name	:	ELIZABETH H MULLINS
Credential	:
Telephone Number	:	601-292-4261

Provider Enumeration Date	:	04/12/2007
Last Update Date	:	05/30/2013

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