Healthcare Provider Details

I. General information

NPI: 1033190129
Provider Name (Legal Business Name): MAE PHYSICIANS SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2005
Last Update Date: 04/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1190 N STATE ST STE 102
JACKSON MS
39202-2413
US

IV. Provider business mailing address

PO BOX 12673
JACKSON MS
39236-2673
US

V. Phone/Fax

Practice location:
  • Phone: 601-968-1790
  • Fax: 601-292-4531
Mailing address:
  • Phone: 601-968-1790
  • Fax: 601-292-4531

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. CARLA GLAZE
Title or Position: ADMINISTRATOR
Credential:
Phone: 601-968-1790