Healthcare Provider Details

I. General information

NPI: 1265450597
Provider Name (Legal Business Name): MARK ANDREW MCLEAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST
JACKSON MS
39216-4500
US

IV. Provider business mailing address

101 SAWMILL CV
MADISON MS
39110-7040
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-5582
  • Fax:
Mailing address:
  • Phone: 601-790-4411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number19370
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: