Healthcare Provider Details

I. General information

NPI: 1255883690
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: 11/02/2016
Last Update Date: 11/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST JMM SUITE 2525
JACKSON MS
39216-4500
US

IV. Provider business mailing address

1405 N STATE ST SUITE 300
JACKSON MS
39202-1642
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-6441
  • Fax: 601-815-0434
Mailing address:
  • Phone: 601-984-4540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QE0800X
TaxonomyEndoscopy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KEVIN COOK
Title or Position: CEO
Credential:
Phone: 601-984-6441