1013990530 NPI number — MISSISSIPPI STATE DEPARTMENT OF HEALTH

Table of content: (NPI 1013990530)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013990530 NPI number — MISSISSIPPI STATE DEPARTMENT OF HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MISSISSIPPI STATE DEPARTMENT OF HEALTH
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:
1013990530
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/30/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
797 S JACKSON ST
Provider Second Line Business Mailing Address:
ROUTE 1 BOX 1049
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38851-7662
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-456-3791
Provider Business Mailing Address Fax Number:
662-456-3979

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
797 S JACKSON ST
Provider Second Line Business Practice Location Address:
ROUTE 1 BOX 1049
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38851-7662
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-456-3791
Provider Business Practice Location Address Fax Number:
662-456-3979
Provider Enumeration Date:
11/29/2005

Additional Information

Authorized Official

Authorized Official Last Name:
EDNEY
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
P
Authorized Official Title or Position:
STATE HEALTH OFFICER
Authorized Official Telephone Number:
601-576-7634

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  1381 , 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: 00070500 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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