Healthcare Provider Details

I. General information

NPI: 1467532903
Provider Name (Legal Business Name): MISSISSIPPI STATE HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 11/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3550 HIGHWAY 468 W
PEARL MS
39208-5529
US

IV. Provider business mailing address

PO BOX 157A
WHITFIELD MS
39193-0157
US

V. Phone/Fax

Practice location:
  • Phone: 601-351-8000
  • Fax: 601-351-8301
Mailing address:
  • Phone: 601-351-8000
  • Fax: 601-351-8301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number939
License Number StateMS

VIII. Authorized Official

Name: MR. JAMES G CHASTAIN
Title or Position: DIRECTOR
Credential:
Phone: 601-351-8000