Healthcare Provider Details

I. General information

NPI: 1104857036
Provider Name (Legal Business Name): MICHAEL R. MCMULLAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 01/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST DIVISION OF CARDIOLOGY
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: 601-984-6426
  • Fax: 601-984-6439
Mailing address:
  • Phone: 601-984-5640
  • Fax: 601-984-6439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number13195
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code207RA0002X
TaxonomyAdult Congenital Heart Disease Physician
License Number13195
License Number StateMS
# 3
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number13195
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: