Provider Demographics
NPI:1942424734
Name:MEDICAL FOUNDATION OF CENTRAL MISSISSIPPI, INC
Entity Type:Organization
Organization Name:MEDICAL FOUNDATION OF CENTRAL MISSISSIPPI, INC
Other - Org Name:BAPTIST OCCUPATIONAL MEDICAL CLINIC - MAE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF CLINIC ADMINISTRATION
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:H
Authorized Official - Last Name:MULLINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-292-4261
Mailing Address - Street 1:1513 LAKELAND DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4829
Mailing Address - Country:US
Mailing Address - Phone:601-968-1377
Mailing Address - Fax:601-292-4262
Practice Address - Street 1:1513 LAKELAND DR
Practice Address - Street 2:SUITE 200
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4829
Practice Address - Country:US
Practice Address - Phone:601-968-1377
Practice Address - Fax:601-292-4262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSC02783Medicare ID - Type UnspecifiedMCARE GRP #