Healthcare Provider Details

I. General information

NPI: 1578011417
Provider Name (Legal Business Name): STATE OF MISSISSIPPI-UNIVERSITY OF MISSISSIPPI MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2016
Last Update Date: 09/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

965 AVENT DR STE 100B
GRENADA MS
38901-5045
US

IV. Provider business mailing address

965 AVENT DR STE 100B
GRENADA MS
38901-5045
US

V. Phone/Fax

Practice location:
  • Phone: 662-227-7172
  • Fax:
Mailing address:
  • Phone: 662-227-7172
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code282NR1301X
TaxonomyRural Acute Care Hospital
License Number
License Number State

VIII. Authorized Official

Name: MR. SCOTT WHITTEMORE
Title or Position: CFO GRENADA/HOLMES COUNTY
Credential:
Phone: 662-227-7172