Basic Information
| Provider Information | |||||||||
| NPI: | 1508989039 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDICAL FOUNDATION OF CENTRAL MISSISSIPPI, INC | ||||||||
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| OtherOrganizationName: | BAPTIST OCCUPATIONAL MEDICAL CLINIC - GLUCKSTADT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1151 N STATE ST STE 408 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392022464 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012924261 | ||||||||
| FaxNumber: | 6012924262 | ||||||||
| Practice Location | |||||||||
| Address1: | 118 WEISENBERGER RD | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391105012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6016077940 | ||||||||
| FaxNumber: | 6016077941 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MULLINS | ||||||||
| AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF CLINIC ADMINISTRATION | ||||||||
| AuthorizedOfficialTelephone: | 6012924261 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.