Healthcare Provider Details

I. General information

NPI: 1639898877
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: 08/23/2022
Last Update Date: 05/01/2024
Certification Date: 05/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N. STATE STREET BIG MOUTH BASS CLINIC - SANDERSON TOWER - LEVEL B
JACKSON MS
39216-4500
US

IV. Provider business mailing address

504 CLINTON CENTER DRIVE CBO - SUITE 4300
CLINTON MS
39056
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-6025
  • Fax:
Mailing address:
  • Phone: 601-496-9794
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: JEFFREY GRIMSLEY
Title or Position: CFO
Credential:
Phone: 601-815-6270