Provider Demographics
NPI:1184912024
Name:GLOVER, MITCHELL O'NEAL IV (MD)
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:O'NEAL
Last Name:GLOVER
Suffix:IV
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 NORTH STATE STREET
Mailing Address - Street 2:UNIVERSITY OF MISSISSIPPI MEDICAL CENTER
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4505
Mailing Address - Country:US
Mailing Address - Phone:601-984-5582
Mailing Address - Fax:
Practice Address - Street 1:2500 NORTH STATE STREET
Practice Address - Street 2:UNIVERSITY OF MISSISSIPPI MEDICAL CENTER
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4505
Practice Address - Country:US
Practice Address - Phone:601-984-5582
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-13
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS22834207P00000X
MST-2435207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08632351Medicaid
MSP01627828OtherRAILROAD MEDICARE PTAN
AL195136Medicaid
MS339646YJ5DMedicare PIN