Healthcare Provider Details

I. General information

NPI: 1104114131
Provider Name (Legal Business Name): MICHAEL BRETT MARLIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2011
Last Update Date: 10/06/2017
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

2500 N STATE ST
JACKSON MS
39216-4500
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-5582
  • Fax:
Mailing address:
  • Phone: 601-984-5571
  • Fax: 601-984-5583

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PT0002X
TaxonomyMedical Toxicology (Emergency Medicine) Physician
License Number22798
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: