Healthcare Provider Details

I. General information

NPI: 1952941312
Provider Name (Legal Business Name): THOMAS MCMAHON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2020
Last Update Date: 01/13/2020
Certification Date: 01/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

427 HIGHWAY 51 N
BROOKHAVEN MS
39601-2350
US

IV. Provider business mailing address

427 HIGHWAY 51 N
BROOKHAVEN MS
39601-2350
US

V. Phone/Fax

Practice location:
  • Phone: 601-835-9275
  • Fax: 888-965-6812
Mailing address:
  • Phone: 601-835-9275
  • Fax: 888-965-6812

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number879390
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: