=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194083139
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEDICAL MALL HEALTH SERVICES OF MISSISSIPPI, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/27/2012
-----------------------------------------------------
Last Update Date | 03/12/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 350 W WOODROW WILSON AVE SUITE 499A
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39213-7681
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-700-7709
-----------------------------------------------------
Fax | 877-852-6352
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 350 W WOODROW WILSON AVE. SUITE 499A
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39213-7681
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-700-7709
-----------------------------------------------------
Fax | 877-852-6352
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COO
-----------------------------------------------------
Name | MR. TIMOTHY P MCNEIL
-----------------------------------------------------
Credential | RN
-----------------------------------------------------
Telephone | 202-344-5465
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------