1891965612 NPI number — MISSISSIPPI BAND OF CHOCTAW INDIANS

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 1891965612 NPI number — MISSISSIPPI BAND OF CHOCTAW INDIANS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MISSISSIPPI BAND OF CHOCTAW INDIANS
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:
Provider Other Organization Name Type Code:
6
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:
1891965612
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/02/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
210 HOSPITAL CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHOCTAW
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39350-6781
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-656-2211
Provider Business Mailing Address Fax Number:
601-663-7721

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
135 HOSPITAL CIR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHOCTAW
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39350-6780
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-656-2582
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/07/2008

Additional Information

Authorized Official

Authorized Official Last Name:
ANDERSON
Authorized Official First Name:
PHYLLIS
Authorized Official Middle Name:
J
Authorized Official Title or Position:
TRIBAL CHIEF
Authorized Official Telephone Number:
601-656-5251

Provider Taxonomy Codes

  • Taxonomy code: 313M00000X , with the licence number:  583 , 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: 09015768 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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