Provider Demographics
NPI:1194083139
Name:MEDICAL MALL HEALTH SERVICES OF MISSISSIPPI, LLC
Entity type:Organization
Organization Name:MEDICAL MALL HEALTH SERVICES OF MISSISSIPPI, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:P
Authorized Official - Last Name:MCNEIL
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:202-344-5465
Mailing Address - Street 1:350 W WOODROW WILSON AVE.
Mailing Address - Street 2:SUITE 499A
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39213-7681
Mailing Address - Country:US
Mailing Address - Phone:601-700-7709
Mailing Address - Fax:877-852-6352
Practice Address - Street 1:350 W WOODROW WILSON AVE
Practice Address - Street 2:SUITE 499A
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39213-7681
Practice Address - Country:US
Practice Address - Phone:601-700-7709
Practice Address - Fax:877-852-6352
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-27
Last Update Date:2015-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty