Healthcare Provider Details

I. General information

NPI: 1902346364
Provider Name (Legal Business Name): MEDICAL FOUNDATION OF CENTRAL MS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2017
Last Update Date: 03/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N STATE ST SUITE 210
JACKSON MS
39202-2000
US

IV. Provider business mailing address

1200 N STATE ST SUITE 210
JACKSON MS
39202-2000
US

V. Phone/Fax

Practice location:
  • Phone: 601-714-3202
  • Fax: 601-714-3416
Mailing address:
  • Phone: 601-714-3202
  • Fax: 601-714-3416

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateMS

VIII. Authorized Official

Name: AMY GRISSETT
Title or Position: BILLING MANAGER
Credential:
Phone: 601-944-1717