Healthcare Provider Details

I. General information

NPI: 1295034015
Provider Name (Legal Business Name): MICHAEL QUEEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2011
Last Update Date: 04/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 DOCTORS DR SUITE C
OCEAN SPRINGS MS
39564-5721
US

IV. Provider business mailing address

PO BOX 3488 DEPT #05-113
TUPELO MS
38803-3488
US

V. Phone/Fax

Practice location:
  • Phone: 678-553-8150
  • Fax: 678-553-8152
Mailing address:
  • Phone: 678-553-8150
  • Fax: 678-553-8152

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMD.207646
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number64878
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: