Healthcare Provider Details

I. General information

NPI: 1164539599
Provider Name (Legal Business Name): JAMES R MEDLIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 09/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

606 N JEFFERSON ST
MACON MS
39341-2242
US

IV. Provider business mailing address

PO BOX 480
MACON MS
39341-0480
US

V. Phone/Fax

Practice location:
  • Phone: 662-726-4231
  • Fax: 662-726-4204
Mailing address:
  • Phone: 662-726-4231
  • Fax: 662-726-4204

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number06439
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: