Basic Information
Provider Information | |||||||||
NPI: | 1184912024 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GLOVER | ||||||||
FirstName: | MITCHELL | ||||||||
MiddleName: | O'NEAL | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: | IV | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2500 NORTH STATE STREET | ||||||||
Address2: | UNIVERSITY OF MISSISSIPPI MEDICAL CENTER | ||||||||
City: | JACKSON | ||||||||
State: | MS | ||||||||
PostalCode: | 392164505 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6019845582 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2500 NORTH STATE STREET | ||||||||
Address2: | UNIVERSITY OF MISSISSIPPI MEDICAL CENTER | ||||||||
City: | JACKSON | ||||||||
State: | MS | ||||||||
PostalCode: | 392164505 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6019845582 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/13/2011 | ||||||||
LastUpdateDate: | 03/06/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 22834 | MS | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 08632351 | 05 | MS |   | MEDICAID | P01627828 | 01 | MS | RAILROAD MEDICARE PTAN | OTHER | 195136 | 05 | AL |   | MEDICAID |