1568873636 NPI number — MISSISSIPPI STATE DEPARTMENT OF HEALTH

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 1568873636 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:
1568873636
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/12/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
570 E WOODROW WILSON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39216-4538
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-576-7635
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
166 RATLIFF ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LUCEDALE
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39452-5712
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-947-4217
Provider Business Practice Location Address Fax Number:
601-947-1420
Provider Enumeration Date:
05/12/2014

Additional Information

Authorized Official

Authorized Official Last Name:
ADCOCK
Authorized Official First Name:
MITCHELL
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF ADMINISTRATIVE OFFICER
Authorized Official Telephone Number:
601-576-7635

Provider Taxonomy Codes

  • Taxonomy code: 251K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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