MEDICARE: MISSISSIPPI STATE DEPARTMENT OF HEALTH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251K00000X	Public Health or Welfare Agency

General Provider Information

NPI Number	:	1396156063
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MISSISSIPPI STATE DEPARTMENT OF HEALTH

Provider Business Mailing Address
First Line	:	570 E WOODROW WILSON AVE
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39216-4538
Country	:	US
Telephone Number	:	601-576-7635
Fax Number	:

Provider Business Practice Location Address
First Line	:	6912 WASHINGTON AVE
Second Line	:
City	:	OCEAN SPRINGS
State	:	MS
Zip	:	39564-2133
Country	:	US
Telephone Number	:	228-872-4861
Fax Number	:	228-872-0612

Authorized Official
Title or Position	:	CHIEF ADMINISTRATIVE OFFICER
Name	:	MR. MITCHELL ADCOCK
Credential	:	CAO
Telephone Number	:	601-576-7635

Provider Enumeration Date	:	05/15/2014
Last Update Date	:	05/15/2014

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