Healthcare Provider Details

I. General information

NPI: 1134528821
Provider Name (Legal Business Name): MARK TYNER HAGWOOD D.P.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2014
Last Update Date: 10/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 MAPLE DRIVE SUITE A
RIDGELAND MS
39157
US

IV. Provider business mailing address

137 HIGHWOODS BLVD
MADISON MS
39110-7423
US

V. Phone/Fax

Practice location:
  • Phone: 601-863-9430
  • Fax:
Mailing address:
  • Phone: 601-863-8430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1924
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: