Provider Demographics
NPI:1881636645
Name:MASON, PHYLLIS ELAINE (MD)
Entity type:Individual
Prefix:DR
First Name:PHYLLIS
Middle Name:ELAINE
Last Name:MASON
Suffix:
Gender:F
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:PO BOX 830525
Mailing Address - Street 2:DEPT. #R24
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35283-0525
Mailing Address - Country:US
Mailing Address - Phone:662-842-1758
Mailing Address - Fax:
Practice Address - Street 1:620 CROSSOVER ROAD
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-4944
Practice Address - Country:US
Practice Address - Phone:662-620-7101
Practice Address - Fax:662-842-1457
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS066562085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02284339Medicaid
MS300138467OtherRAILROAD MEDICARE
AL009919405Medicaid
300001102OtherMEDICARE
300001102OtherMEDICARE
MS300138467OtherRAILROAD MEDICARE