Healthcare Provider Details

I. General information

NPI: 1447510581
Provider Name (Legal Business Name): BAPTIST JACKSON HEART CARDIOLOGY CLINIC-CRYSTAL SPRINGS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2012
Last Update Date: 05/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 BOBO DRIVE
CRYSTAL SPRINGS MS
39059
US

IV. Provider business mailing address

1600 N STATE ST SUITE 400
JACKSON MS
39202-1689
US

V. Phone/Fax

Practice location:
  • Phone: 601-292-4261
  • Fax: 601-944-9780
Mailing address:
  • Phone: 601-944-1717
  • Fax: 601-944-9780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: ELIZABETH MULLINS
Title or Position: PRESIDENT
Credential:
Phone: 601-292-4261