Healthcare Provider Details

I. General information

NPI: 1174629257
Provider Name (Legal Business Name): MARY B TAYLOR MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST
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: 888-815-2005
  • Fax:
Mailing address:
  • Phone: 888-815-2005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number28959
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number13304
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: