Healthcare Provider Details

I. General information

NPI: 1053434555
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: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6250 OLD CANTON RD STE 100
JACKSON MS
39211-2946
US

IV. Provider business mailing address

1151 N STATE ST STE 408
JACKSON MS
39202-2464
US

V. Phone/Fax

Practice location:
  • Phone: 601-957-1015
  • Fax: 601-956-9721
Mailing address:
  • Phone: 601-292-4261
  • Fax: 601-292-4262

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine 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