Healthcare Provider Details

I. General information

NPI: 1659348076
Provider Name (Legal Business Name): SOUTHEAST MISSISSIPPI RURAL HEALTH INITIATIVE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2006
Last Update Date: 04/16/2021
Certification Date: 04/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44 BROOKLYN JANICE RD
BROOKLYN MS
39425-9731
US

IV. Provider business mailing address

PO BOX 1729
HATTIESBURG MS
39403-1729
US

V. Phone/Fax

Practice location:
  • Phone: 601-582-1188
  • Fax: 601-582-8844
Mailing address:
  • Phone: 601-545-8700
  • Fax: 601-450-0231

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateMS

VIII. Authorized Official

Name: GEROLDEAN DYSE
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 601-545-8700