MEDICARE: MAE PHYSICIANS SURGERY CENTER, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA1903X	Ambulatory Surgical Clinic/Center

General Provider Information

NPI Number	:	1033190129
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAE PHYSICIANS SURGERY CENTER, LLC

Provider Business Mailing Address
First Line	:	PO BOX 12673
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39236-2673
Country	:	US
Telephone Number	:	601-968-1790
Fax Number	:	601-292-4531

Provider Business Practice Location Address
First Line	:	1190 N STATE ST
Second Line	:	STE 102
City	:	JACKSON
State	:	MS
Zip	:	39202-2413
Country	:	US
Telephone Number	:	601-968-1790
Fax Number	:	601-292-4531

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MRS. CARLA GLAZE
Credential	:
Telephone Number	:	601-968-1790

Provider Enumeration Date	:	11/07/2005
Last Update Date	:	04/10/2014

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