Healthcare Provider Details

I. General information

NPI: 1972689313
Provider Name (Legal Business Name): EAST MISSISSIPPI STATE HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2006
Last Update Date: 07/27/2020
Certification Date: 07/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4555 HIGHLAND PARK DRIVE
MERIDIAN MS
39307-2903
US

IV. Provider business mailing address

P.O. BOX 4128 WEST STATION
MERIDIAN MS
39304-4128
US

V. Phone/Fax

Practice location:
  • Phone: 601-581-7562
  • Fax: 601-581-7676
Mailing address:
  • Phone: 601-581-7562
  • Fax: 601-581-7676

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number1230
License Number StateMS

VIII. Authorized Official

Name: MR. WILLIAM HAMRICK ENTREKIN
Title or Position: BUSINESS SERVICES DIRECTOR
Credential:
Phone: 601-581-7969