Basic Information
| Provider Information | |||||||||
| NPI: | 1295283687 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDICAL FOUNDATION OF CENTRAL MS INC | ||||||||
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| OtherOrganizationName: | BAPTIST MEDICAL CLINIC-BELHAVEN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 N STATE ST | ||||||||
| Address2: | SUITE LL-10 | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392022000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017146411 | ||||||||
| FaxNumber: | 6017146421 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 N STATE ST | ||||||||
| Address2: | SUITE LL-10 | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392022000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017146411 | ||||||||
| FaxNumber: | 6017146421 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2016 | ||||||||
| LastUpdateDate: | 09/15/2016 | ||||||||
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| AuthorizedOfficialLastName: | GRISSETT | ||||||||
| AuthorizedOfficialFirstName: | AMY | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6019441717 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MS | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.