Basic Information
| Provider Information | |||||||||
| NPI: | 1295034015 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | QUEEN | ||||||||
| FirstName: | MICHAEL | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3488 | ||||||||
| Address2: | DEPT #05-113 | ||||||||
| City: | TUPELO | ||||||||
| State: | MS | ||||||||
| PostalCode: | 388033488 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6785538150 | ||||||||
| FaxNumber: | 6785538152 | ||||||||
| Practice Location | |||||||||
| Address1: | 22 DOCTORS DR | ||||||||
| Address2: | SUITE C | ||||||||
| City: | OCEAN SPRINGS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395645721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6785538150 | ||||||||
| FaxNumber: | 6785538152 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2011 | ||||||||
| LastUpdateDate: | 04/11/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | MD.207646 | LA | Y | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 64878 | MS | N | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.