Healthcare Provider Details

I. General information

NPI: 1003098096
Provider Name (Legal Business Name): MEDICAL FOUNDATION OF CENTRAL MISSISSIPPI, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2007
Last Update Date: 06/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N STATE ST SUITE 420
JACKSON MS
39202-2001
US

IV. Provider business mailing address

PO BOX 2153 DEPT 1947
BIRMINGHAM AL
35287-0001
US

V. Phone/Fax

Practice location:
  • Phone: 601-355-3353
  • Fax: 601-355-3365
Mailing address:
  • Phone: 601-355-3353
  • Fax: 601-355-3365

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM 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