Provider Demographics
NPI:1295034015
Name:QUEEN, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:QUEEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3488
Mailing Address - Street 2:DEPT #05-113
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38803-3488
Mailing Address - Country:US
Mailing Address - Phone:678-553-8150
Mailing Address - Fax:678-553-8152
Practice Address - Street 1:22 DOCTORS DR
Practice Address - Street 2:SUITE C
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-5721
Practice Address - Country:US
Practice Address - Phone:678-553-8150
Practice Address - Fax:678-553-8152
Is Sole Proprietor?:No
Enumeration Date:2011-03-18
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.207646207L00000X
MS64878207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology