Healthcare Provider Details

I. General information

NPI: 1508020397
Provider Name (Legal Business Name): MEDICAL FOUNDATION OF CENTRAL MISSISSIPPI, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2008
Last Update Date: 09/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 MARSHALL ST SUITE 101
JACKSON MS
39202-1651
US

IV. Provider business mailing address

501 MARSHALL ST SUITE 101
JACKSON MS
39202-1651
US

V. Phone/Fax

Practice location:
  • Phone: 601-969-5105
  • Fax: 601-969-5106
Mailing address:
  • Phone: 601-969-5105
  • Fax: 601-969-5106

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease 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