Healthcare Provider Details

I. General information

NPI: 1114040607
Provider Name (Legal Business Name): MEDICAL FOUNDATION OF CENTRAL MISSISSIPPI, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 04/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2946 LAYFAIR DRIVE SUITE 102
FLOWOOD MS
39232
US

IV. Provider business mailing address

1151 N STATE ST STE 504
JACKSON MS
39202-2476
US

V. Phone/Fax

Practice location:
  • Phone: 601-292-4261
  • Fax: 601-292-4262
Mailing address:
  • Phone: 601-292-4261
  • Fax: 601-292-4262

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: ELIZABETH H MULLINS
Title or Position: DIRECTOR OF CLINIC ADMINISTRATION
Credential:
Phone: 601-292-4261