Healthcare Provider Details

I. General information

NPI: 1184694036
Provider Name (Legal Business Name): SOUTHEAST MISSISSIPPI RURAL HEALTH INITIATIVE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2006
Last Update Date: 04/15/2021
Certification Date: 04/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1016 HIGHWAY 42
SUMRALL MS
39482-9634
US

IV. Provider business mailing address

PO BOX 1729
HATTIESBURG MS
39403-1729
US

V. Phone/Fax

Practice location:
  • Phone: 601-758-4214
  • Fax: 601-758-0614
Mailing address:
  • Phone: 601-545-3700
  • Fax: 601-450-2493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: GEROLDEAN DYSE
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 601-545-8700