Provider Demographics
NPI:1679843452
Name:MEDICAL MALL SERVICES OF MISSISSIPPI, LLC
Entity Type:Organization
Organization Name:MEDICAL MALL SERVICES OF MISSISSIPPI, LLC
Other - Org Name:MEDICAL MALL HEALTH SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:CLAYTON
Authorized Official - Last Name:BARDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-459-4766
Mailing Address - Street 1:2820 BLADENSBURG RD NE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20018-4106
Mailing Address - Country:US
Mailing Address - Phone:202-459-4766
Mailing Address - Fax:
Practice Address - Street 1:350 W WOODROW WILSON AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39213-7681
Practice Address - Country:US
Practice Address - Phone:610-672-2733
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-10
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service