1952724650 NPI number — SOUTHEAST MISSISSIPPI RURAL HEALTH INITIATIVE, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952724650 NPI number — SOUTHEAST MISSISSIPPI RURAL HEALTH INITIATIVE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHEAST MISSISSIPPI RURAL HEALTH INITIATIVE, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PETAL SCHOOL CLINIC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1952724650
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/06/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1729
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HATTIESBURG
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39403-1729
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-545-3700
Provider Business Mailing Address Fax Number:
601-450-2493

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
36 PANTHER STADIUM DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PETAL
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39465-3632
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-450-2144
Provider Business Practice Location Address Fax Number:
601-450-2145
Provider Enumeration Date:
01/31/2014

Additional Information

Authorized Official

Authorized Official Last Name:
RAY
Authorized Official First Name:
KAYE
Authorized Official Middle Name:
Authorized Official Title or Position:
CHEIF EXECUTIVE OFFICER
Authorized Official Telephone Number:
601-545-8700

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 251023 . This is a "MS MEDICARE PTAN" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 02622599 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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