Healthcare Provider Details

I. General information

NPI: 1295283687
Provider Name (Legal Business Name): MEDICAL FOUNDATION OF CENTRAL MS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2016
Last Update Date: 09/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N STATE ST SUITE LL-10
JACKSON MS
39202-2000
US

IV. Provider business mailing address

1200 N STATE ST SUITE LL-10
JACKSON MS
39202-2000
US

V. Phone/Fax

Practice location:
  • Phone: 601-714-6411
  • Fax: 601-714-6421
Mailing address:
  • Phone: 601-714-6411
  • Fax: 601-714-6421

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateMS

VIII. Authorized Official

Name: AMY GRISSETT
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 601-944-1717