Healthcare Provider Details

I. General information

NPI: 1194083139
Provider Name (Legal Business Name): MEDICAL MALL HEALTH SERVICES OF MISSISSIPPI, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2012
Last Update Date: 03/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 W WOODROW WILSON AVE SUITE 499A
JACKSON MS
39213-7681
US

IV. Provider business mailing address

350 W WOODROW WILSON AVE. SUITE 499A
JACKSON MS
39213-7681
US

V. Phone/Fax

Practice location:
  • Phone: 601-700-7709
  • Fax: 877-852-6352
Mailing address:
  • Phone: 601-700-7709
  • Fax: 877-852-6352

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. TIMOTHY P MCNEIL
Title or Position: COO
Credential: RN
Phone: 202-344-5465