Healthcare Provider Details

I. General information

NPI: 1790272961
Provider Name (Legal Business Name): MARY BALL RUFFIN MARKOW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2018
Last Update Date: 07/20/2021
Certification Date: 07/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST
JACKSON MS
39216-4500
US

IV. Provider business mailing address

116 GREEN GLADES
RIDGELAND MS
39157-8662
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-1000
  • Fax:
Mailing address:
  • Phone: 601-573-8496
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number28887
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: