Provider Demographics
NPI:1104857036
Name:MCMULLAN, MICHAEL R (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:MCMULLAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-5640
Mailing Address - Fax:601-984-6439
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:DIVISION OF CARDIOLOGY
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-6426
Practice Address - Fax:601-984-6439
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13195207RC0000X, 207RA0002X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RA0002XAllopathic & Osteopathic PhysiciansInternal MedicineAdult Congenital Heart Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0119549Medicaid
MSP01402426OtherRR MEDICARE
MS060000904Medicare PIN
MS275606YJ5DMedicare PIN
MS0119549Medicaid
MS275606YKDBMedicare PIN