Basic Information
| Provider Information | |||||||||
| NPI: | 1003098096 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDICAL FOUNDATION OF CENTRAL MISSISSIPPI, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BAPTIST NEUROLOGICAL ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2153 | ||||||||
| Address2: | DEPT 1947 | ||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352870001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013553353 | ||||||||
| FaxNumber: | 6013553365 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 N STATE ST | ||||||||
| Address2: | SUITE 420 | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392022001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013553353 | ||||||||
| FaxNumber: | 6013553365 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2007 | ||||||||
| LastUpdateDate: | 06/28/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MULLINS | ||||||||
| AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
| AuthorizedOfficialMiddleName: | H. | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF CLINIC ADMINISTRATION | ||||||||
| AuthorizedOfficialTelephone: | 6012924261 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 204D00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine & OMM |
ID Information
| ID | Type | State | Issuer | Description | 01627892 | 05 | MS | MEDICAID | C02783 | 01 | MS | MEDICARE GROUP NUMBER | OTHER | DA0407 | 01 | RR MEDICARE | OTHER |