Healthcare Provider Details

I. General information

NPI: 1992906598
Provider Name (Legal Business Name): MAECENAS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 ROBERT MCDANIEL DRIVE
HAZLEHURST MS
39083-0146
US

IV. Provider business mailing address

PO BOX 146
HAZLEHURST MS
39083-0146
US

V. Phone/Fax

Practice location:
  • Phone: 601-894-5110
  • Fax: 601-894-5154
Mailing address:
  • Phone: 601-894-5110
  • Fax: 601-894-5154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier09015686
Identifier TypeMEDICAID
Identifier StateMS
Identifier Issuer

VIII. Authorized Official

Name: GERRI L HILL CHAUCE
Title or Position: PRESIDENT
Credential: MD
Phone: 601-894-5110