MEDICARE: STATEWIDE HEALTHCARE SERVICES, INC

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	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1629199351
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STATEWIDE HEALTHCARE SERVICES, INC

Provider Business Mailing Address
First Line	:	1 N STATE ST
Second Line	:	SUITE 1500
City	:	CHICAGO
State	:	IL
Zip	:	60602-3302
Country	:	US
Telephone Number	:	800-404-3191
Fax Number	:	312-704-0022

Provider Business Practice Location Address
First Line	:	3829 I-55 NORTH
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39211
Country	:	US
Telephone Number	:	601-982-7311
Fax Number	:	601-982-7462

Authorized Official
Title or Position	:	EXECUTIVE VICE PRESIDENT
Name	:	MR. JOEL DAVIS
Credential	:
Telephone Number	:	18004043190

Provider Enumeration Date	:	04/02/2007
Last Update Date	:	08/22/2020

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